Complicated complications.

Setting up for the surgical meeting

Today is Thursday, and unique to Thursdays is that there is no Hospital Morning Meeting. Instead, there are supposed to be departmental meetings – although the surgical ones seem to have slipped a little. This morning however, I had been ‘volunteered’ to lead a session on hernias – it did not require much persuasion given my interest in education and my primary aim of being here to help the department move forward. This took place in theatres and it seemed to be very well received. I was also delighted with the performance of the mini-projector that I had indulged in buying before leaving the UK (everyone likes a good gadget – it’s not much bigger than a phone!). As things came to a close, I was mentally relaxing into a catch up day (as there didn’t seem to be much on surgically)… but perhaps not….

At the end of the meeting, one of the O&G surgeons asked for my help with a patient who had returned to the hospital following a laparotomy 6 days ago for a difficult (massive) uterine ‘myoma’. There was green discharge from the midline wound – clearly enteral (bowel) contents. Whilst I was in no doubt that this was likely to be challenging, a relook laparotomy was required and so the arrangements were made. It took a bit of time to get the patient into theatre, but then we were on.

The etiquette here is for the surgeon to be scrubbed and preparing the instruments, before anaesthesia is commenced. The lead nurse anaesthetist was away, but her able deputy seemed happy to undertake the GA involving intubation and muscle relaxation. However, as I was gowning up I was aware that securing the airway (getting the breathing tube into the right place) was proving difficult. Now I am surgeon, but I have a massive respect for what my anaesthetic colleagues do both here and in the UK. Anaesthesia is one of those specialties that goes smoothly the vast majority of the time…. but when it goes wrong, it goes very wrong… and quickly. The patient had desaturated (was running out of oxygen) and as I looked on it was apparent that the difficult intubation had successfully intubated the stomach (this is bad). The saturations were now unrecordable. This is very very bad. I offered to help and somewhere inside me I remembered some of what I was taught in my early SHO years in A&E and on ICU. A number of key principles also came strongly to mind (I suspect as a result of the crossover meetings / dialogue in theatre that we have with our anaesthetic colleagues). I pulled out the tube and managed to ventilate the patient. Times goes painfully slowly as you wait for some positive signs that what you are doing is working (and patience may not be prudent either), but as the seconds felt like minutes, slowly the saturations came back 50s (very bad), 60s (still very bad), 70s (still very bad, but we’re making progress), 80s…. 90s (thank *&%£ for that) and finally up to 100. Whew. We were safe. I re-preoxygenated the patient (anaesthetic readers are probably horrified by this tale, but will be proud that I did this) and then tried to intubate the patient. Now, whilst I am rusty, I know what I am supposed to see – not least because I get an excellent view of the anatomy every-time I do an OGD (flexible camera test of the stomach) back in the UK. I was definitely not seeing what I was supposed to. It took three patient attempts (calm in the face of adversity is a good thing here), trying different positions and also the use of a boogey (a guide wire). In the end, it was definitely a ‘blind’ intubation (there is a technical term for this, grade something or other), but it was successful. To say this was stressful, underplays how I felt a little (like massively). This  definitely ranks close to the top of my all-time most difficult clinical moments. Now I just had to do the laparotomy.

Instruments from the UK

Somehow, I composed myself and got back into my 'A game' for the operating. The abdomen was a car crash – technical term for a mess – and as it turns out, also one of the most difficult operations I have ever had to do. The anatomy was hugely distorted with the residual cavity of this ‘myoma’ occupying the entire lower abdomen, displacing everything else above the umbilicus. It had been extensively stuck to multiple loops of bowel and so there was a significant ‘rind’ left in-situ. The residual cavity was full of clotted blood and there was a large hole in a densely adherent loop of small bowel. I also found a tiny perforation in the colon. A lot of careful dissection (only made possible using some of the instruments I brought from the UK), patience and perseverance actually resulted in a technically very satisfying end result. Now all the patient needs to do is wake up…. and heal….

….fingers and toes crossed.

On arriving home, and recounting the events of my day in explaining why I missed lunch and was home so late, a very pertinent question was asked by my amazing wife: “When exactly was the last time you intubated a patient?”…..