Something Strange about Dr. Strange

Most love a good operating room scene where a brilliant mind and steady hand save the day. Dr. Strange fulfills this role in his self-titled movie and was most enjoyable to watch.

However, there is one scene that concerned me.

See anything strange besides the man who carries the name?

The two main characters are creating a burr hole in the skull to be able to retrieve the bullet lodge near the medulla. The are in full sterile attire except for their masks.

Several years ago, I was called to the OR to assist with the removal of a brain tumor guided with ultrasound. No one in that room went without a mask covering their mouth and noise. In fact, I was not even allowed to enter the suite without a mask in place.

All of the surgeons, nurses and surgical assistants surrounding the table also wore face shield to protect their eyes from any splatter of the patient’s biological fluids.

So you can imagine my disdain when watching the movie, Dr. Strange, and discovering two surgeons hovering over a patient’s head, creating burr holes in his skull without masks. Upon further research, the wearing of masks in the OR has caused some controversy.

According to Lisa Maragakis, Senior Director of Epidemiology and Infection Control at John Hopkins Health System, some studies have shown the absence of a mask in the OR “have virtually no bearing on the patient outcomes when surgeries are performed by healthy doctors in sanitary operating rooms.” (Maragakis, 2016) In some European hospitals, surgeons are no longer required to wear masks.

However, she also discusses what happens when a surgeon sneezes. Personally if it were my open brain, I’d not want my surgeon’s droplets nestling into my head wound.

Here in the US, most hospital and operating room protocols still require our surgeons to don the traditional surgical mask and encourage facial shields.

Perhaps, one day that will change, but right now, I’m glad wearing surgical masks are not strange.

References:

Sugarman, J. (2016). What Do Surgical Masks Really Protect Against? Retrieved May 28, 2018.
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Shannon Moore Redmon writes romantic suspense stories, to entertain and share the gospel truth of Jesus Christ. Her stories dive into the healthcare environment where Shannon holds over twenty years of experience as a Registered Diagnostic Medical Sonographer. Her extensive work experience includes Radiology, Obstetrics/Gynecology and Vascular Surgery.

As the former Education Manager for GE Healthcare, she developed her medical professional network across the country. Today, Shannon teaches ultrasound at Asheville-Buncombe Technical Community College and utilizes many resources to provide accurate healthcare research for authors requesting her services.

She is a member of the ACFW and Blue Ridge Mountain Writer’s Group. Shannon is represented by Tamela Hancock Murray of the Steve Laube Agency. She lives and drinks too much coffee in North Carolina with her husband, two boys and her white foo-foo dog, Sophie.

Author Question: Scythe Wound to the Chest (1/2)

Sue Asks:

The year is 2006 and a seventeen-year-old male gets stabbed through the right side of his chest all the way through to the back, but the blade (a hand scythe) that could potentially stop him from bleeding out gets removed. Naturally, he starts bleeding out.

I already know a lot about what goes into stabilizing him: Checking the ABCs, IVs for blood and fluid replacement, intubation (an endotracheal tube), but my question is, what is the exact treatment for this type of injury in a surgical theatre? What are the indications that he may need a thoracotomy or a lobectomy? Or is it as simple as a chest tube to treat the hemopneumothorax, connecting him to a ventilator, and then suturing the lacerations in his lung?

Jordyn Says:

Thanks so much for sending me your question, Sue. Very intriguing scenario you have here!

Let’s first clarify some of these medical terms for readers. A thoracotomy is a surgery that involves removing the lung. Lobectomy can be removal of any lobe of organs such as your thyroid, liver, or lung. In this case, you’re referring to the lung. A hemopneumothorax is a collection of blood and air inside the chest wall that is usually relieved by placement of a chest tube. Pneumothorax is an abnormal collection of air in the chest between the lung and the chest wall– also typically relieved by placement of a chest tube (though some very small ones may just be watched).

I asked a physician friend (thanks, Liz!) her thoughts on your questions.

She says the following:

Since the patient is unstable, he needs a thoracotomy by default. Other indications for surgery would be blood draining from the chest tube at greater than 100 milliliters per hour. The lungs cannot be sutured. Generally, bleeding vessels are either tied off or cauterized and the bronchi (the larger breathing tubes) are repaired. If the lobe is severely damaged then it does get removed.

Author Question: Surgery for Shrapnel to the Abdomen

Naomi Asks:

My protagonist is a surgical resident at large hospital, and I want to write a scene where she is in the OR treating a piece of shrapnel entering the patient’s large intestine with no exit wound.

It took quite a long time to get the patient any sort of medical attention and he has multiple myeloma. I’ve read from my research that myeloma can cause increase inflammation and compression of blood vessels causing coagulation and lessening internal bleeding.

A few questions:

I want to know the chance of my character surviving the surgery. I’m aware since there was no exit wound, and the piece of shrapnel didn’t hit any vital organs, that it would be high chance. However, since he received medical attention rather late (perhaps between half an hour and an hour) I want to know the chance of him actually surviving.

What would be the role of the surgical resident in this scenario? I don’t necessarily just want her to be cleaning up, but I want this to be as accurate as possible.

How long will it take to recover from this surgery?

Are they any complications that could happen during the surgery? If so, please list the major ones.

Jordyn Says:

For this question, I went to one of the best OR types I know . . . my friend Kim Zweygardt who works as a Certified Nurse Anesthetist (CRNA).

Kim Says:

First of all, let’s talk about length of time.

If the shrapnel missed all vital organs and major blood vessels, the length of time to treatment is minor. Are you talking from time of injury? If so, it takes some time for EMS to get to the scene, stabilize the patient, and get to the ER. It takes time in the ER for the nurses to start IVs, for the ER doctor to assess the patient, and get lab and radiology studies to diagnose. It takes time for the surgery to be scheduled and the OR crew to set up for the case.

In a large teaching hospital, is there an OR open or do they have to wait? If the patient isn’t bleeding out, it’s urgent but not life and death. It’s unlikely for the patient to be in the OR from time of injury in half an hour or even an hour.  For instance, in a stat C-section with the patient and crew in house, it’s supposed to be decision to incision within thirty minutes and it’s sometimes difficult to hit that timeline. It takes time to transfer the patient and get the OR ready so I wouldn’t be concerned with that time affecting the outcome in this scenario.

Chances of surviving the operation? It’s kind of a misunderstanding that lots of people die in the OR! Your chances of surviving something is very good in the OR because everything and everybody is there to help you survive— all ways to stop bleeding, medications to resuscitate, etc.

The biggest risk is if the shrapnel was close to major blood vessels that could be nicked by the sharpness during removal.  Most likely scenario is if it’s embedded in the bowel then they would just resect the bowel. In other words, remove the piece of bowel damaged along with the shrapnel. That’s normally done using a special stapler and then reconnected.

It’s possible depending on damage that they’d do a temporary colostomy. Let the bowel heal and go back later to reconnect it.

Biggest worry is infection. Normally when you resect the bowel you do a bowel prep so the colon is empty of stool. The shrapnel itself is dirty but having to resect an unprepped colon— risk of infection is very high and serious enough to cause death. But it’s not an immediate thing. They’d put him on antibiotics but within 24-48 hours he’d have symptoms if infected.

Role of the resident— depends on how advanced they are in their training. If early in residency, assisting. Holding retractors. If more advanced they could do most of the case. In all cases, if an attending surgeon is there, the resident will be left to close the surgical wound, write the orders for post op, and follow up on the patient in the ICU or PACU (Post Anesthesia Care Unit). What they wouldn’t do is clean things up! That is left to the nurses and techs.

His recovery time? If no infection then three to five days if healthy and their bowels are moving to where they can eat, drink, go to the bathroom, etc. With infection recovery time could be weeks or even a month or more.

Hope this helped and best of luck with your story!
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Kimberly Zweygardt is a Christ follower, wife, mother, writer, blogger, dramatist, worship leader, Certified Registered Nurse Anesthetist, a fused glass artist and a taker of naps. Her writings have been featured in Rural Roads Magazine, The Rocking Chair Reader, and Chicken Soup for the Soul Healthy Living Series on Heart Disease. She is the author of Stories From the Well and Ashes to Beauty, The Real Cinderella Story and was featured in Stories of Remarkable Women of Faith. She lives in Northwest Kansas with her husband where their nest is empty but their lives are full. For more information: www.kimzweygardt.com.

Reader Question: Medication Charges for OR

This reader question was asked in the comments and Kim gave a very detailed answer that I thought should be posted as well.

Susan Asks:

I have a question. I have had several surgeries, including foot surgery where a block was used. The list of medications on my bill were astounding! I understand the induction agent, narcotics and versed, but what is the anesthesia gas for? Just to keep the patient asleep? I love these posts!

Kim Says:

Hi, Susan!

Thanks for your question. One of the fascinating things about anesthesia is that there are as many different ways to give an anesthetic as there are different types of patients. Anesthesia is based on the type of surgery you are having, your own health/anesthetic surgery, preferences of the surgeon as well as the experience and preference of your anesthetist.

In the old days, you breathed in an anesthetic gas until you were asleep. If you ever had anesthesia with ether, you’d understand why we’ve continually looked for better ways to render patients insensible to pain.

Another way was to “block” the pain impulses by the use of local anesthesia either as a “field block” (blocking the area similar to what a dentist does), as a spinal or epidural, or a block of an extremity. One thing we’ve learned through the study of pain is that blocking the area with a local anesthetic decreases the over all amount of pain a person has post op. Because the nerve impulses to the brain are blocked, the brain doesn’t respond by releasing stress chemicals that cause inflammation until after the local wears off which means that less pain and inflammation happens over all.

So the “modern” way of doing an anesthetic has changed to what we call a multi-modal approach.

1) The block was to prevent pain and to keep you comfortable for a time after surgery.

2) The induction agent (versus breathing enough gas to go to sleep which isn’t especially pleasant in an adult) puts you to sleep initially, while the Versed (an amnestic) and narcotic (pain relief) provide other pieces of the anesthetic puzzle.

3) The anesthetic gas is added after you are asleep from the induction agent and also provides amnesia and pain relief. It also helps to control blood pressure changes from surgical stimulation or the use of a tourniquet in extremity surgery (used to keep the sterile field “bloodless” and expedite the surgery).

With the advent of outpatient surgery, patients no longer snooze the day away waking up from their anesthetic. They need to be deeply asleep and then awake enough to go home in a matter of hours. Using a multi-modal approach (using a combination of drugs for different reasons) is much more effective than each of those drugs by themselves.

For example, without the use of the anesthetic gas, much more narcotic is required. Without the narcotic, much more gas is required to do the same job. Every drug has side effects which increase with dosage and in the case of anesthetic gasses, time.

Using a combination of drugs allows us to keep the side effects to a minimum. It is a common misconception that we give a patient an anesthetic drug and then coast through the surgery and like magic they wake up when it is over. Even surgeons think so.

In reality, though it seems like a large number of medicines, each one has a specific purpose and one of the reasons anesthesia is safer and more pleasant than the old days.

Probably more info than you wanted, but I enjoy when people who are interested in what I do. I’ve been a CRNA for 34 years and I still find it absolutely fascinating!

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Kimberly Zweygardt is a Christ follower, wife, mother, writer, blogger, dramatist, worship leader, Certified Registered Nurse Anesthetist, a fused glass artist and a taker of naps. Her writings have been featured in Rural Roads Magazine, The Rocking Chair Reader, and Chicken Soup for the Soul Healthy Living Series on Heart Disease. She is the author of Stories From the Well and Ashes to Beauty, The Real Cinderella Story and was featured in Stories of Remarkable Women of Faith. She lives in Northwest Kansas with her husband where their nest is empty but their lives are full. For more information: www.kimzweygardt.com

The Face Behind the Mask: Part 5/5

This is our final post with certified nurse anesthetist Kimberly Zweygardt. It’s been a pleasure to have her blog at Redwood’s Medical Edge. I know I’ve learned several ways to increase the conflict in my OR scenes. What are some ways you’ll add conflict? If you’re just joining us you can find Part I, Part II, Part III, and Part IV by following the links.

Thank you, Kim, for your fantastic insight into the world of the OR.

Finally, the complication that movie nightmares are made of: recall under anesthesia.

Recall under anesthesia is defined as remembering something while surgically anesthetized. The most common scenario involves the patient receiving muscle relaxants without enough amnesia and/or pain control provided. Some patients recall being in pain but unable to move while others have no pain but can remember things being said during the operation.

How can this happen?

Thirty years ago we had patients being told their heart wasn’t strong enough for anesthesia. With the advent of Open Heart surgery, anesthesia techniques changed that were safer for the heart, so we now operate on people who are on drugs that mask the normal response to pain. It becomes harder to asses if the patient is truly asleep if the heart rate and blood pressure don’t change related to pain.

And we also have what I call the “drive through” surgery phenomena. Surgery used to mean recovering in the hospital for several days. Now, you are dismissed within hours of the operation. Anesthetics must be shorter acting or patients not as deeply anesthetised during the operation so they will be safe to go home. I believe that is why recall is on the rise.

But we also must account for how we are fearfully and wonderfully made.

I read an interesting study that monitored depth of anesthesia and recall. Volunteers were anesthetized using an EEG to measure depth of anesthesia. They were not having surgery, but when they reached surgical depth of anesthesia, the anesthetist stood up and said, “There’s something wrong! They are blue! There’s something wrong.”

There was nothing at all wrong. They waited a period of time then woke the volunteer up. A small percentage spontaneously remembered that event and their fear. The rest were hypnotized to see if they recalled the event. A percentage became agitated, bringing themselves out of the trance at that point. The rest were able to recall under hypnosis what had been said during their anesthetic. What the study showed was that we are not just a physical body and though our physical body is anesthetised, our spirit may be aware of what is happening much like the near death experiences where the spirit hovers over the body.

I personally know of several incidences where a patient could not recall events in surgery but acted upon something said while they were asleep. Some were positive changes and others were tragic.

The BIS monitor was designed to prevent recall but it isn’t standard of care and only offers that most patients at a certain number are truly “asleep.” Even so, I am careful what is said in the patient’s presence.

But when it comes to fiction, I can think of several scenario’s to rachet up the drama and suspense related to anesthesia. How about you?

***Content originally posted  February 11, 2011.***

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Kimberly Zweygardt is a Christ follower, wife, mother, writer, blogger, dramatist, worship leader, Certified Registered Nurse Anesthetist, a fused glass artist and a taker of naps. Her writings have been featured in Rural Roads Magazine, The Rocking Chair Reader, and Chicken Soup for the Soul Healthy Living Series on Heart Disease. She is the author of Stories From the Well and Ashes to Beauty, The Real Cinderella Story and was featured in Stories of Remarkable Women of Faith. She lives in Northwest Kansas with her husband where their nest is empty but their lives are full. For more information: www.kimzweygardt.com

The Face Behind the Mask: Part 4/5

We’ve been learning a lot from Kimberly Zweygardt, CRNA. This is the fourth post in a five part series. You can find Part I, Part II, and Part III by following the links. Kim is filling us in on great ways to add conflict to your operating room scenes by covering some complications.

Welcome back, Kim.

Anesthesia is sometimes defined as a controlled emergency. Here are some complications that would create great tension for our characters.

The number one cause of death related to anesthesia is also the most preventable: aspiration pneumonia. When someone eats or drinks 8 hours before surgery then are anesthetized, the vomitting/gag reflex is lost and anything in the stomach flows into the trachea and lungs causing pneumonia. If the patient isn’t NPO 8 hours, surgery may be delayed or canceled. However, if they ate lunch then fell out of a tree, surgery can’t be delayed. Drugs are given while pressure is put on the esophogus and the breathing tube gotten in as quickly as possible to prevent aspiration(called RSI or Rapid Sequence Induction).

During the pre-op interview, we ask about family complications with anesthesia. Two major complications with anesthesia are genetic.

The first is a genetic defiency of an enzyme (psuedocholinesterase) that metabolizes the muscle relaxant, Anectine (also called Succinylcholine or nicknamed “Sux”).  Instead of being metabolized in10 minutes, the drug effect lasts hours with the patient on a ventilator until it wears off(2 hours to 8 hours).  It is not life threatening except for being unable to breathe! In other words, the deficiency is easily diagnosed and the patient (and family) is instructed to avoid the drug. There are other drugs that are longer acting and reversible with medications that can be substituted in the future.

The other complication is also genetic but is life threatening. Certain anesthetic agents trigger a hypermetabolic state called malignant hyperthermia (MH). Though called hyperthermia, the increased body temperature is a late symptom. If the patient’s temp is rising before you diagnose it, it is too late.

The first alert is when the muscle relaxant causes the jaw muscles to tighten instead of relax. At that point, I am on hyper alert, looking for other symptoms such as increased heart rate (also a sign of an anxious patient or a light anesthetic), arrhythmia’s (premature heart beats called PVC’s) and a rising CO2 (carbon dioxide) level despite adequate ventilation. The urine becomes dark brown as the body breaks down muscles and calcium and potassium are released into the blood stream. This is every anesthesia provider’s nightmare.

Every OR has a poster describing MH treatment and the phone number to MHAUS, an organization dedicated to education and treatment of MH. If MH is suspected, someone calls the hotline to get an expert on the phone. With proper treatment, mortality ranges from 5% in some literature to 20% in other. At one time, MH was 95% fatal. The key is early recognition and treatment. Delaying treatment while trying to figure out if it is MH or not accounts for higher mortality.

Treatment involves turning off all anesthetic agents and ventilating the patient with 100% O2. Surgery is stopped and the surgeon “closes” or sutures the incision shut. All new hoses and the CO2 absorber is changed on the anesthesia machine. Dantrolene, a powdered drug to reverse MH, is mixed with 60 cc of sterile water and given. Dantrolene is difficult to mix and a dose is up to 36 vials so one of the first things done after diagnosis is to get plenty of help to do nothing but mix drug.

All the treatment is too extensive to go into here, but if interested, check out www.MHAUS.org.

***Content originally posted February 4, 2011.***

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Kimberly Zweygardt is a Christ follower, wife, mother, writer, blogger, dramatist, worship leader, Certified Registered Nurse Anesthetist, a fused glass artist and a taker of naps. Her writings have been featured in Rural Roads Magazine, The Rocking Chair Reader, and Chicken Soup for the Soul Healthy Living Series on Heart Disease. She is the author of Stories From the Well and Ashes to Beauty, The Real Cinderella Story and was featured in Stories of Remarkable Women of Faith. She lives in Northwest Kansas with her husband where their nest is empty but their lives are full. For more information: www.kimzweygardt.com

The Face Behind the Mask: Part 3/5

We’re continuing our five part series with certified nurse anesthetist Kimberly Zweygardt.

Welcome back, Kim.

So far, we’ve met the characters in the OR and discussed the setting. Today, let’s talk about things that could go wrong including anesthesia complications.

We’ve all read about wrong patient or wrong operation or surgeons operating on the opposite leg, hip, etc. Safegaurds, like the time out, are designed to prevent this, but what if it increases plot tension?

Also, the OR is its own little world—only staff and patients allowed, but there was a case where someone impersonated a doctor. What did the nurse say when she found out he wasn’t a real surgeon? “I couldn’t tell. He was wearing a mask!” In a large teaching hospital there are students of all types and the OR gets much more crowded. It would be possible for someone to sneak in with mayhem on their mind, although safegaurds like doors to the dressing rooms with keypad entries have become common.

The OR is a very busy place and patient care comes first. As the case ends and the patient wakes up, there is lots of hub bub.My concern is if my patient is pain free and breathing before taking them to the PACU (Post Anesthesia Care Unit), not about the drugs which locked up unless being used. While I’m gone, the room is “turned over” (cleaned and readied for the next case). Nurses, scrub technicians and housekeeping are in and out. In some OR’s an anesthesia tech cleans and restocks the anesthesia supplies, changing the mask and breathing circuit on the anesthesia machine so that when I return, all I have to do is draw up drugs for the next patient.

Due to the nature of the OR, the anesthesia cart is unlocked so that the tech can restock drugs and supplies. What would happen if someone had murder on their mind?

Drug companies sometimes use the same labels for different drugs. For example, Drug A is in a 2cc vial and slows down the heart. The label is maroon and the vial has a maroon cap. It is clearly labeled as Drug A. Drug B also is a 2 cc vial with a maroon label and has a maroon cap but Drug B increases the blood pressure. What happens if the pharmacist sends the wrong drug because he recognized the colored label and grabbed it? Or if both drugs are in the anesthesia cart, but one vial gets put in the wrong drawer along with vials that look identical? Or the patients blood pressure is dangerously low and in my hurry, I grab the wrong drug and slow down the heart causing the blood pressure to plummet even lower? What if it wasn’t an accident?

For your comfort, practitioners are know about “look alike” drug vials and take special precautions to prevent errors. Don’t be afraid if having surgery, but what fun would that be for our characters? Remember this blog post is about getting the medical details right, not making our characters happy!

***Content originally posted January 28, 2011.***

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Kimberly Zweygardt is a Christ follower, wife, mother, writer, blogger, dramatist, worship leader, Certified Registered Nurse Anesthetist, a fused glass artist and a taker of naps. Her writings have been featured in Rural Roads Magazine, The Rocking Chair Reader, and Chicken Soup for the Soul Healthy Living Series on Heart Disease. She is the author of Stories From the Well and Ashes to Beauty, The Real Cinderella Story and was featured in Stories of Remarkable Women of Faith. She lives in Northwest Kansas with her husband where their nest is empty but their lives are full. For more information: www.kimzweygardt.com