I’m Awake

I worked most of my career as an Obstetrical Anesthesiologist, providing pain relief (analgesia) to women in labor.  I have said hundreds of times, “there are few people that like me better than a woman in labor … maybe their partner”.

Obstetrical Anesthesia is a professions of stark contrasts.  On the one hand, it is a profession where one can experience the joys, the tears, the smiles that parents experience when a new little one is added to their family.  On the other hand it is also a profession that can bring stresses not present in other anesthesia theaters.  Women of child bearing age are usually young and healthy.  The unborn child is ‘a golden child’ in its parents minds, perfect in every way.  Nothing bad is supposed to happen to either the mother or their unborn child.  One of the common phrases I used to tell the residents I was training was  – “you need to be very very careful and attentive to every detail, because, if something goes bad, it can go bad very quickly.  The obstetric ward is one of the few places you can have more than 100% mortality, but 200% or 300% because you could lose not just the mother but the unborn child (children) as well.  Things can go from very good to very bad in a hurry and one needs to be on their game at all times.

During pregnancy, for the pain of labor, we primarily use low concentrations of either spinal (single needle injection in the back) or epidural (placing a very tiny plastic tube in the back so multiple injections can be given) local anesthetics to provide analgesia (a lesser level of anesthesia, not one suitable for surgery).  The moms can still move their legs, can have limited oral intake, and can often get up to use the bathroom if supported by the nurse.  For surgery, say for tubal ligations, forceps deliveries or cesarean sections  we use spinal or epidural anesthetics with more concentrated local anesthetics to provide surgical level of anesthesia.

Spinal anesthesia is a very popular anesthetic technique for cesarean sections.  It allows the mothers to be wide awake during the surgery.  They are completely comfortable and usually do not require sedation for the procedure.  This allows the significant other (oh how we have moved to being mindful of all of the nuances of the family unit these days) to be in the operating room during the delivery.  There is commonly a bit of nausea and vomiting at one point in the surgery, but that is even a more important reason to have the significant other present, they can manage that with a small basin and the suction from our anesthesia machine while I attend to more important matters.  It is a way of really engaging that person in the delivery, lol.

Spinal anesthesia for cesarean section is a very very safe anesthetic.  However – isn’t there always a ‘however’ in most of life’s activities – one has to always be on the lookout for signs of trouble brewing.  One of these bits of trouble one can get in to is the dreaded Bezold–Jarisch reflex.  This is very rare, but potentially catastrophic reflex that can happen in a very small percentage of the population.  It involves a variety of cardiovascular and neurological changes which cause hypopnea (excessively shallow breathing or an abnormally low respiratory rate), hypotension (abnormally low, non-life supporting blood pressure) and bradycardia (abnormally low resting heart rate to the point of standstill) that can proceed to cardiac arrest – named after two physicians, a German physician Albert von Bezold and as Austrian physician Adolf Jarisch.  For whatever reason the reflex seems a bit more common in the young very healthy patient – maybe because their reflexes are much more highly tuned than in those of us at advanced age.

As a result, I at the beginning of a spinal anesthetic, would pay no attention to anything else happening in the room but only to the patient’s heart rate and blood pressure.  At the first sign of slowing of the heart rate the resident would feel a not so gently tap to their head and I would say – ‘get on that now’.  If caught early it is entirely reversable with the proper medications, but one has to be every mindful that it is ‘out there ever ready to rear its ugly head’.

I became a true believer in this reflex very early in my career.  At that time, some 35 years ago, I would occasionally do cases at our regional trauma center.  One day I found myself in a room with an Orthopedic surgeon – whose brother by the way was one of the early early game show hosts of the Wheel of Fortune- now how did I remember that when I can’t remember the current day of the week!!  The patient was a very health 35 year old young man.  As luck would have it, my resident and I had placed a spinal anesthetic for a knee procedure when the nurse announced they had a little problem.  The operating room bed the patient was on was not radio-opaque and thus they couldn’t use the C-arm, a special x-ray that beams through the table to help the surgeon align all of the new prosthetic parts.  With a forced smile on my face, I helped them bring a new bed into the room so we could move the patient to the correct bed.  I cautioned the resident – who at that point had considerable experience in anesthesia – to keep a close eye on the patient.  With an eye-roll and a nod of the head from the resident it seemed the instruction was understood – but looking back, maybe the importance of the warning had gone unheaded.

Shortly after the patient had been moved to the new bed, and positioned for the surgery, I noticed that his heart rate was taking a nose dive, and more quickly than you can say – “hey we are in trouble” he was in cardiac arrest.

My reflex in moments like this is – calmly but loudly say to the resident, get a milligram of Atropine and a milligram of Epinephrine (adrenaline) in this guy now !!  I always have both drawn up and ready to go with any spinal anesthetic, so that was easily done.

My second announcement was to the surgeon and I said, “ Dr. B, your patient just arrested”.  Lol, if the patient is doing good it is my patient, if a problem develops I think the surgeon should carry some of the load – lol, lol.

He said, “what should I do”.  I said, “I think you should start CPR”.

An interesting thing about cardiac arrests.  If they are witnessed and people are immediately available, one can try a pre-cordial thump – a very hard sharp blow – to the middle of the chest while a defibrillator is being attached to the patient.  It seldom works, but if it were to work, it would take a blow that only an Orthopedic surgeon could deliver.

In a wink of the eye, a nod of his head, Dr. B. stepped up alongside of the patient and delivered a pre-cordial thump that made the patient bounce higher than they usually do when shocked with a defibrillator.  For an instant I stood there in utter disbelief.  Was the surgeon angry at the patient for dying or did he in fact understand that what he had just done was an acceptable medical intervention.  Unbelievably, and to my nearly uncontrolled joy, the patient converted to a very slow, but acceptable, heart rate and had a detectable pulse how be it with a low but life sustaining blood pressure.  Many times in my career I had heard myself say to residents, “slow heart and low blood pressure are so much better than no heart rate and no blood pressure !!!  By this time the drugs were in and things began to normalize quickly.

An interesting fact of the ‘ole Bezold–Jarisch reflex’  is that once recognized and treated there is no chance of recurrence so the patient was no longer in danger surgery could continue.

About a year later the Anesthesia Department Chair at the time published a report of 20 cases Bezold-Jarisch reflex nation-wide that had been reported to him reminding the Anesthesia world of the dangers of this reflex and how best to manage it.  My case was case #16 in that report.

An experience like this changes one’s practice for the remainder one’s career.

 

 

Well back to the OB floor.

On this particular day, the OB floor was busy with women in labor.  As an added attraction we had an urgent cesarean section in the wings for a young, healthy mother who was in labor but whose baby was on the large side and was breech.  A normal delivery really carried too much risk for the baby so an urgent cesarean section was planned.  Unfortunately we had to proceed expeditiously such that we could not wait for her husband to arrive from a town north of Seattle where he was a construction worker working on a new apartment complex.

My resident and I discussed with the young lady what would happen during the case, she agreed to a spinal anesthetic so we decided to move forward with the case as soon as possible.  Things were getting busier and I wanted to get at least this one case out of the way.  We took the lady back to the operating room, placed an IV, per usual, gave her a fluid bolus, placed on all the appropriate monitors, turned her on her side and slid a spinal in with little or no effort.  Just as we rolled her to her back and place her in a little left tilt to improve blood flow to the placenta, the second resident I had working with me came in the room and said there was a women that really needed a labor epidural, she was really really uncomfortable, and per usual, the husband was handling the labor pains far worse than his wife.  Both residents were experienced and it was common to get a case started in the operating room and then I would be able to leave that room and help the other resident.  I told him to go set up for the epidural and that I would be there in about 5 minutes.  We got the lady comfortable, reassured her things we going fine.  The surgical nurse was prepping her instrument tray and I told the Obstetricians to be ready to prep the woman’s abdomen and put the drapes up in 2-3 minutes.

I looked around, said I was needed in another room and was everyone comfortable with my leaving.  Everyone agreed and my resident gave me a thumbs up.

I left the operating room and stopped at the scrub sink to wash my hands.  Just as I was finishing I heard someone say, “Oh my god, she has arrested!”  For a second, the thought crossed my mind, … ‘it could be another person’s patient’ …, but knowing fair well I was the only anesthesiologist on the floor at the time I steeled myself and hurried back in to the room.  As I came into the room was absolutely quiet, not a sound, complete silence.  Most concerning for me as an anesthesiologist was the lack of the comforting beep beep beep sound of the heart monitor.  I looked at the monitor and there was nothing but a perfectly flat line going across the monitor screen.  My resident was standing at the head of the operating room bed, the Obstetricians were standing to one side of the room, and the scrub nurse was standing there in her sterile surgical gown, sterile gloves on with her hands held in front of her and not a word was being said.  At times like this, occasionally some of the familiar language that I grew up with – what we endearingly call “Norman talk” (Norman was my dad’s name) or “Bunker talk” (Bunker Hill Smelter was where he worked) – would come streaming out of my mouth.  I asked in as professional way as possible, “What the Hell is going on in here?”  My resident, frozen at the head of the operating room bed, looking down at the patient, barely managed to say, “she has arrested!”  “Well, someone get on her chest, start CPR for gods sake!”

Announcing that you need to start CPR during a case is a very difficult thing to do for an anesthesiologist.  Yes, we know it has to be done, and it has to be done quickly.  But in many ways it feels a bit like you are a failure.  Needing to start CPR can feel like you did something wrong, somehow you have failed as an anesthesiologist.  However, in the vast majority of cases it is the consequence of a patient’s own physiology, not a reflection of your skills.

I quickly moved to the far side of the bed and started chest compressions.  I instantly knew what was going on – the ole J-B reflex and I knew we had to act fast.  As I looked up I notice tears were forming up in my  residents eyes.  I thought, now is not the time to cry!  You can cry and shake your underwear out after this is over.  I shouted, “get a milligram of Atropine, and a milligram of Epinephrine in her right now”, and then get on her airway.  Yes those are the same exact words I had used some 30 years earlier, and unfortunately a couple other times in the interim.  I looked across the room, everyone was also still frozen in their tracks.  I announced in a very directed voice to the docs, get me the code cart.  They looked directly at me and one of them said, “I’m not sure we know where it is”.  I thought this cannot be happening to me!!  I looked at the scrub nurse, called her by name and said “get me the code cart”.  She looked at me and said, “Dr. Ross, I am scrubbed and sterile sorry”.  For a second I wanted to say,    “Where are the camera’s? Where is Alan Funt?    I  must be on Candid Camera!”      I was about to tell her that we had hundreds of pairs of gloves and hundreds of scrub gowns so go get the damn code cart, when at that moment my second resident entered the room.  I was unaware that at least one of the nurses in the room had the enough presence of mind to push the code blue button on the wall.

I quickly assigned him to manage the patient’s airway as my other resident was still not capable of performing adequately.

What seemed like decades, but I am sure was a few short minutes, I heard the hospital code team coming down the hallway to the operating room, code cart in tow.  I shouldn’t have, but I decided to hold CPR for a few seconds to see if we were able to get a rhythm back.  When I stopped I took a quick look at the monitor.  While doing CPR there is too much interference to see a rhythm on the monitor.  I was relieved to finally see a rhythm but it was still incredibly low – 10-12 beats a minute – and it should be well over 60.  I restarted doing CPR to continue circulating the drugs we had given.  As the code team burst through the door and started getting the defibrillator attached to the patient, so somewhere I heard a very weak voice.  I wasn’t sure exactly where it came from but for a second time I heard, “I’m aaawwwaaake”. Not being sure what I had heard I continued doing chest compressions.  About 10 seconds later I again heard, louder this time, “I’m awake”.  I stopped doing compressions and looked down at the patient.  She was just opening her eyes.  She looked up at me, appeared quite confused and said, “My chest hurts”.  An incredible wave of relief swept over me and I was so glad she was able to feel that her chest hurt from my compressions.  The alternative was unthinkable.

A few minutes later her husband arrived.  I took him to a patient room, explained very carefully and slowly what had happened.  I stressed that is was an exaggerated reflex that certain people have and that it would not recur during this surgery.  I reassured him there was very little risk if we continued the case.  The patient was totally numb from the anesthetic and we really needed to deliver the baby.

We continued the case.  A nice healthy little boy was delivered and there were more tears than normal in that room when we all heard the little ones first cry.

I re-visited the mom and dad several more times during the mother’s stay.  We monitored her in the telemetry unit, a special cardiac unit near the ICU, for a couple days to make sure she did not develop a concerning heart rhythm.  I ordered all the cardiac enzyme studies I could think of both to reassure the patient but also to reassure myself.  The mother left the hospital with a formal letter from the Anesthesia department explaining to the next anesthesiologist what had happened, what to be on the lookout for, and may be needed if that were to happen again.

There were still several issues that needed to be dealt with around the residents performance.  On the good side, the resident went on to be a very good anesthesiologist, in part, due to that very case.