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

March 22, 2018March 14, 2018 / Jordyn Redwood / Leave a comment

We’re continuing with Sue’s question regarding a scythe injury to the chest to a seventeen-year-old male. You can find Part 1 here.

Sue Asks:

I have a few follow-up questions regarding the surgery. Is it possible for a thoracotomy to be done by two people? The hospital in my story is severely understaffed and only two doctors are available to perform the surgery. There are not enough nurses on staff either, and it’s the middle of the night. Is that feasible or should I tweak the story so more people are available to make sure the teen makes it out alive?

And lastly, what kinds of medications would be pushed through the IV to sedate and/or paralyze him for surgery?

Jordyn Says:

This was a great question to ask my OR expert friend, Kim Zweygardt, who works as a CRNA.

Here are her thoughts.

Most hospital’s policy states that an RN must be in the room for assessments and patient safety. The bare minimum OR staff would be a circulator (RN), scrub tech, anesthesiologist, and surgeon. If you want chaos in your story— take out the scrub tech because the doctor will have to figure out the instruments for himself versus calling out and them being handed to him.

A patient this unstable would be intubated in the ER. Generally they are given a pain medication (Fentanyl), a benzodiazepine (Versed) for the amnesic effect, and the paralyzing agent will vary but Succinylcholine was common in your time frame of 2006.

Once in the OR— they would give him anesthetic gases to keep him down. I don’t see your scenario playing out without a anesthesiologist on hand.

Hope this helps and best of luck with your novel.

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

March 19, 2018March 14, 2018 / Jordyn Redwood / Leave a comment

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

February 15, 2018February 14, 2018 / Jordyn Redwood / Leave a comment

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.

The Use of Hypothermia Post Cardiac Arrest

November 2, 2017October 29, 2017 / Jordyn Redwood / Leave a comment

Emily Asks:

I am playing around with one of my character’s being shot life threateningly, but of course it’s gotta be something he recovers from with time.

This character is in his late 20s and in good health before the incident takes place.

At first, I was toying around with the idea of making the gunshot wound similar to what Kate Beckett had in the show Castle at the end of season three. The trouble is, I do not know how medically realistic her wound was, as you have pointed out Castle’s medical inaccuracies before. If you have possibly seen the episodes in question, could you give me some feedback on the medical aspects of Beckett’s shooting?

In relation to this, her heart supposedly stopped twice during the whole ordeal. I have been researching induced comas, and while they seem to be used for patients having more of a direct injury to the head, in the case when a victim’s heart stopped twice and is resuscitated both times, would there be any reason to keep them in an induced coma for a time due to lack of oxygen to the brain?

Then, after researching, I am playing around with giving this guy a collapsed lung from the bullet, which is small caliber.

1. In what hypothetical cases would this kind of injury require immediate surgery?

2. Are there any complications that could be serious enough for the said character to have to go back into surgery at a later time?

3. My character happens to be a bass singer for an acapella band. Would a collapsed lung affect his career at all even after he made a full recovery?

Thank you for taking the time to read and respond to my questions!

Jordyn Says:

Beckett’s Gunshot Wound:

I had to go back and find some videos that were related to this. Shockingly, I found this scene pretty medically accurate. I found one that showed her coding one time. Though I definitely could have missed some. The determination to put someone in therapeutic hypothermia or targeted temperature management (as now termed) related to their heart stopping is dependent on whether or not they wake up immediately after their code.

A patient that wakes up spontaneously and quickly after a pulse is restored has intact neurological function. Those that remain comatose have a concern for neurological injury related to oxygen loss to the brain during the resuscitation and therefore the medical team could choose to put the pt in a “hypothermic” state to try and prevent this neurological injury.

This is slightly different from a medically induced coma that patients with traumatic brain injury might be placed in to prevent brain swelling. The difference is actively cooling the patient. I have not seen the use of hypothermia in the traumatically brain injured population (though this does appear to be an area of study), but use of medically induced comas, yes.

There are definite guidelines that the American Heart Association has put out that outline this course of treatment. You can find one such article here.

If your character codes and doesn’t wake up– then this would be a reasonable course of action medically, but written under the guidelines in the article.

In regards to your specific questions.

1. It’s more likely than not that a gunshot wound to the chest would go to surgery, particularly if the patient presents with any abnormal vital signs especially low blood pressure. There’s just so much there that could be damaged. The heart. The lungs. The blood vessels.

2. Yes, there could be a number of scenarios where the character could require more surgery such as a blood vessel that’s leaking that’s not found the first time during surgery and continues to bleed. Infection– specifically some sort of abscess formation could be another reason, but that would take some time to develop.

3. I don’t personally foresee a problem with his acapella career after his lung is healed. It would take time to get to the point where he was. If you wanted to affect his career, a patient who is intubated (placed on a breathing machine) can develop vocal cord damage as a rare complication.

Best of luck with your story!

Reader Question: Medication Charges for OR

July 7, 2017June 23, 2017 / Jordyn Redwood / Leave a comment

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!

*********************************************************************************
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

Author Question: Small Town Care for Complex Medical Patient

May 22, 2017May 18, 2017 / Jordyn Redwood / 2 Comments

Holly Asks:

In the very first chapter of the story I’m working on, the main character gets sent to hospital. The character in question is a sixteen-year-old female who has been missing for eleven years. She is found in the woods surrounding the town it’s set in and presents naked, severely malnourished, heavily pregnant, and with a gunshot wound to her leg. There are other superficial injuries that one might get when attempting to flee nude through dense woodland. The town and hospital are relatively small. The hospital has seventy-five doctors and forty-five nurses on staff and it’s in a fairly isolated location.

I’ve got a few questions:

1 – Would the hospital I’ve described be able to treat a patient in this condition? What would be the basics of this treatment?

2 – Is there a procedure hospitals have in place for patients who act violent? My character hasn’t been around people for eleven years. She’s borderline feral and she attacks a doctor when she wakes up. Since she’s pregnant, I wasn’t sure if they’d be able to sedate her.

3 – Can doctors share information about patients with police officers? Since she’s a missing person and a minor, the police are going to be involved but I’m not sure how much doctors can share.

Jordyn Says:

Hi, Holly! Thanks so much for sending me your questions. These are complex ones for sure.

Question #1: Could a small town rural hospital be able to care for this patient? Maybe. One thing I want to clear up is your ratio of doctors to nurses. Usually, there are many more nurses in a given area than physicians so maybe adjust your numbers if you’re making a point about this in your novel.

When I first read your question, I thought the medical care aspects might be cared for by a rural hospital, but it was going to be a tough undertaking. This victimized teen is going to need, at a minimum, five services to be in place to stay in a rural hospital— a good general practitioner (to manage her overall care), a nutritionist (for the malnutrition), a surgeon (surgical evaluation of the gunshot wound), an OB/GYN (for the pregnancy), and a psychiatrist and/or psychologist (just because she’s been held hostage for eleven years.) Already that list is going to be tough and likely insurmountable for the area you mention.

What tilts the balance for me in saying she would have to go to a large, urban center are the psychiatric issues you mention in your second question.

Question #2: Yes, hospitals have procedures in place for violent patients, but the staff and mental health care specialists who will be required to manage her care are likely to be found at an urban center.

Violent patients are generally managed in a step-wise fashion. Can talking to them de-escalate their behavior? Is there something they’re requesting that we can give them to get them to calm down? Does she have some sort of object (like a stuffed toy) that giving her would help if it was safe for her to have?

If it’s more a fight response because of what she’s been through and she’s a danger to herself and others then she’d have to be restrained and placed under one on one observation. This type of patient can tax staffing resources which is another reason why transfer might be best.

Each drug is given a category related to its potential to harm a developing baby that is easily searchable via the internet. The categories go from Category A to Category D. Category A is deemed safest to D which has proven adverse reactions in humans. Just because a drug is listed as Category C or D doesn’t mean it might not be used. Several things would be taken into account— what we call risks versus benefits.

For instance, if she was late in her pregnancy, the doctors could risk it because the baby is fully developed. This is tough, though. Many physicians will err on the side of what’s safest for the pregnancy. However, you can’t leave a patient restrained forever and some form of psychiatric medication could be warranted here.

Question #3: Can doctors share information with police officers? Yes, they can. There is actually a special provision listed in HIPAA (the law that rules over patient privacy) that allows for this. Police officers mostly need to document what “serious bodily injury” the patient has suffered so they can determine what criminal charges to bring against a perpetrator.

The other thing to consider is the size of the local police department. Small towns may not even have their own police department but rely on the county sheriff’s office and/or state police to handle the investigation of this crime.

I actually think the best place for this teen would be the closest children’s hospital. Children’s hospitals have specialized teams in place to manage issues particularly around crimes against children. The caveat would be her pregnancy— for which she would likely deliver at an adult center.

Hope this helps and good luck with your story!

The Face Behind the Mask: Part 5/5

May 19, 2017April 3, 2017 / Jordyn Redwood / Leave a comment

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.***

The Face Behind the Mask: Part 4/5

May 17, 2017April 3, 2017 / Jordyn Redwood / 1 Comment

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.***

The Face Behind the Mask: Part 3/5

May 15, 2017April 3, 2017 / Jordyn Redwood / Leave a comment

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.***

The Face Behind the Mask: Part 2/5

May 12, 2017April 3, 2017 / Jordyn Redwood / 2 Comments

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

Welcome back, Kim.

Last post we discussed who is in the OR. Today let’s talk about the OR setting then discuss the anesthetic.

The OR is a cold, sterile, hard surface, brightly lit environment that is all about the task instead of comfort. Cabinets hold supplies, the operating room bed is called a table, Mayo stands hold instruments for immediate use during the operation and stainless steel wheeled tables hold extra instruments and supplies. IV poles, wheeled chairs/stools and the anesthesia machine and anesthesia cart complete the setting.

When a patient comes in, the staff does a “time out.” The circulating nurse, the surgeon and anesthetist all say aloud that it is the correct patient and procedure. It sounds like this, “This is Mrs. Harriet Smith and she’s having cataract surgery on her left eye.” Once done, the staff swings into action, the circulator “prepping” the surgical site (washing it off with a solution to kill the germs) while the scrub nurse prepares the instruments after “gowning and gloving” (putting on sterile gown and gloves). Meanwhile, the surgeon “scrubs” meaning washing his hands at the sink outside the room. When he is done, he’ll enter the room to get gowned and gloved. Before all this is happens, I’ve started my care of the patient.

I meet the patient before this to fill out a health history specific to anesthesia. Are they NPO (Have they had anything to eat or drink after midnight)? Do they have allergies? Have they ever had an anesthetic and if so, any complications? Has anyone in their family ever had complications with anesthesia? Then I ask about medications and other health problems so I can choose the best anesthetic. But an even bigger job is reassuring them that I am there to take care of them.

When they come to the OR, I attach monitors—EKG heart monitor, blood pressure cuff, and pulse oximetry (a small monitor that fits on the finger to measure the oxygen levels in the blood). Once the monitors are on, I give medicines for the “induction” of anesthesia. As the patient goes to sleep, they are breathing oxygen through a face mask. Drugs include the induction agent (most likely Propofol), narcotics (Fentanyl most common), an amnestic (Versed which provides amnesia), plus a muscle relaxant (Anectine)that paralyzes the muscles. When asleep, the breathing tube is placed using a laryngoscope that allows me to visualize the vocal chords. Then the anesthetic gas is turned on.

I am with the patient through the whole operation, watching monitors, giving medications and making adjustments. At the end, I reverse the muscle relaxants, turn off the anesthetic gas, and begin the “emergence” process waking the patient up.

Now, that’s the norm but we’re writers where normal is boring! Next post I’ll let you in on all the things that can go wrong!

***Content originally posted January 21, 2011.***