Saturday, 16 October 2010

Total spinal and a missing Laerdel bag...

I was on call last night and I got a call at about 10pm from MC who was the registrar overnight telling me he had an issue that I need to know about.

He did an epidural on Labour ward, and he had given her a test dose of 3mL of 2% Lignocaine with Adrenaline, and he waited what he thought was a reasonable period of time and then gave her 5mL of Ropivacaine 0.2%.  After he finished injecting the 5mL she stated that her legs were heavy and numb, which rapidly progressed to not feeling well, then unable to move her arms and then difficulty breathing.  He had laid her down when he injected the 5mL of Ropivacaine, and when she felt unwell he did a BP which was 80 systolic.  He then gave some aramine from the drawer and when the patient complained of difficulty breathing he asked the nurses for a Laerdel bag, and the nurses pushed the Emergency button as well.  They came back with the arrest trolley but were unable to procure a Laerdel bag, by which stage the patient was really unable to breathe and oxygen saturations were dropping.  MC stated that he explained to the patient that he would have to breathe for her and had to perform mouth to mouth whilst waiting for a Laerdel bag.  The MET team arrived and he asked them for a Laerdel bag and they didn't have one on them, the trolley was coming in the lift.

O+G registrars turned up and he informed them that they would need theatres urgently and the anaesthetic nurse arrived from theatres with a Laerdel bag and intubation equipment and then the patient was anaesthetised and paralysed and intubated.  They proceeded to LSCS and the baby was born fit and well, and they transferred the mother up to intensive care, by which stage she was spontaneously breathing and awake and obeying commands and extubated.

MC said he had to perform mouth to mouth for about 5 minutes!!!  And the husband was present when he first started to do mouth to mouth and was freaked out.  MC went to ICU to see the patient afterwards, and the baby was brought up to her, and the patient and the husband thanked Matthew for everything, and seemed to be very happy with the outcome despite the complication that occurred.

I could not sleep after MC told me the events that happened and I asked him if he needed me to come in, he said he didn't, but I decided to go in anyway, as it was a pretty major traumatic event in terms of anaesthetic complications, and give him a bit of consultant support, reassure him that he did the right thing and managed the situation well.  I think he was surprised to see me at the early hours of morning and we talked for more than an hour about the situation, and just general conversation as well afterwards.  I think I left him feeling supported and reassured, though of course he would still feel like an idiot (though I told him that he did all the correct things and managed things well).  Poor MC.... I am glad everything turned out but geez, we are going to get on top of the fact that there was no resuscitation equipment in Labour ward quick smart!!!

17/10 update:

I was wondering if I was being a bit over the top by going in.  I know when I had my bad incident at work in ICU, when the consultant came in to chat I felt so supported that I wanted to make sure I did that for my own registrars.  When I turned up I was wondering to myself if MC thought I was being an idiot or just wished I went away.  But I got an email later that morning from him:

Hi J,

Thanks again for coming in, it has made me feel much better.
I know you don't believe in subdural block but the more I read up this seems that it could have been a "subdural" catheter. No CSF via tuohy needle and no CSF able to be aspirated via catheter. Onset wasn't very rapid, but sort of intermediate. Very extensive block. progressive respiratory incoordination rather than just sudden apnoea, relatively little cardiovascular instability. All of which fits with the literatures description of a subdural block. Or maybe I'm just trying to convince myself because for some reason it just seems a little less worse to me... more bad luck then just my incompetence.

I saw her this morning. She has no residual block and was happily breast feeding her son. She has minimal pain and no headache (yet).

Anyway, have a good day. Hope you have a good party tomoorow for Julian.

Thanks again.M

20/10 Update:

God I felt bad!  I told 2 colleagues, AC and PC, and when I got to work on Tuesday apparently EVERYBODY knew about what happened to MC.  I felt terrible!  AC  said he waited about half an hour before he started to SMS everyone...  Poor MC!  He said he told JL, who was a good friend of his at Liverpool who was on night shift and JL asked him if he slipped the tongue in!  The funny thing is, that because I'm quite close to the incident (I was on call after all), that all these things didn't even enter my mind.  But after the incident, I can see why everyone is laughing about it (in a good natured way, ie they look at MC as doing a fantastic job, heroic almost!  And that they can tease him because there was a good outcome).  Others have asked if he had taken a mint beforehand, was the patient good looking, etc.  I did his ITA online form with him yesterday and we had a bit of a talk about the whole thing, and he seems ok now, though he wishes they weren't teasing him about it.  He said that he was teaching a medical student in his theatre about bag mask ventilation and the medical student mentioned that there was a registrar who did mouth to mouth on a patient... and MC was said that he had to tell that student it was true, and it was him.  Looking back at it now, I think people will think of MC as a legend which is quite amusing!  I am still very proud of him, I have defended him tooth and nail when people ask about it in any kind of disparaging way.  Sometimes I think of him as a prized student or something!  I only hope that I can be the kind of consultant that he looks up to as well.

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