Sep
17

An Anesthesia Machine Ooooops

By

David Avitar ArrowheadIn answer to Dawn’s inquiry about the nity gritty of anesthesia and the problems that can come up I have enclosed a correspondence from a very close friend and class-mate of mine who had an anesthesia apparatus setup problem. The Anesthesia machince checkout is one of the first things that we learn to do as beginning practitioners. The file of the Anesthesia Apparatus Checkout Recommendations is available on this site.

Hi guys,

We never get to talk too much so I just wanted to share one of my never ending idiot-girl stories in hopes that you learn from me.

At Hudson (an out-patient facility ed.), you are responsible for changing your circuit in-between cases. I was in a “hurry” and got distracted as I switched out the circuit and forgot to put on the reservoir bag…and obviously I didn’t do a pressure check.

So there I am with an apneic, un-preoxygenated patient and no immediate means to ventilate. Don’t go there, I am embarrassed and have learned the hard way. Fortunately, my patient is fine (I can’t even begin to imagine the worst case scenario)……..why do we have to learn the hard way?

Never ever ever skip or forget a pressure check.

Goodnight guys

Interesting isn’t it how little things can make the biggest difference. This is what it is like to do anesthesia – the constant scanning and checking through lists of set up and detail; Patients Airway is OK, Ventilations, Saturation, Blood Pressure, ECG monitor, IV is running and patent and the list goes on and on; timing of drugs to appropriate surgical stimulation, induction sequences and the Art of Anesthesia – the emergence. One little missed set or timing issue can cause an anesthetic embarrassment and patient compromise. It’s a tough job but someone has got to do it. Are you Man or Woman enough for this?

I wanted to share an experience of mine that happened just a month ago while I was in the Ear Nose and Throat operating room when the director of our anesthesia program came for a facilities check and student evaluation. This visit by Dr. Gold was during my sojourn at Arrowhead Regional Medical Center and a General Surgery rotation. During Dr. Gold’s visit she popped into my room while I was in the middle of a maxillary fracture repair. These cases with ENT are done with a shared airway as well as with the patient turned away from you and the head completely covered with drapes. It was the third case of the day and I had one to follow.

The room turn-over at Arrowhead is very fast and the nursing staff and ancillary support is very good at getting the room ready for the next case. Usually the CRNA or MDA that the student SRNA is working with is present during the patients wake up and tracheal extubation and stays in the room to turn the anesthesia machine over for the next case while the patient is taken to recovery. That is if you are lucky.

Earlier I had taken my second case to the recovery room and had drawn up all of my medications to start the next case as well as reviewed the preoperative examination and paperwork for the third case. The patient was dropped off in PACU and I went directly to the preoperative holding area to pick up the next patient. That was my first mistake. I did not go back to the room to recheck that the staff had properly turned the machine over.

Everything with the beginning of the case went perfectly; here I was in the middle of the case number three, the maxillary fracture repair, and the director of the program was in my room interviewing me and quizzing me on my anesthetic choices. All of a sudden the anesthesia machine starts complaining with an alarm. I am already distracted because of the presence of Dr. Gold in the room and her being there to see how I am doing. Running through the alarm check list I see that there is a disconnect in the circuit. There is now no ventilation and no CO2 return on the screen. Great Gods help me.

The patient is turned away from me and I am sharing the airway with the surgeons because they are operating on the jaw. I think, “I taped the hell out of that endotracheal tube and secured it very well”. Yet I still am wondering if the endotracheal tube is secure and the anesthesia circuit is connected. Quickly I jump under the drapes which are completely covering the patient and assess the circuit to the endotracheal tube – the circuit is connected just fine. I come out from under the drapes and am looking at the machine as the CRNA that I have been working with just happens to come is. He says casually from across the room, “hey there, your circuit is disconnected and on the floor.” Of course it is disconnected but where. Dale astutely was able to see the disconnection of the anesthesia circuit from the anesthesia machine at the place where the circuit attaches to the machine. Now I see the problem and fix it quickly. All is well and no harm is done except to my ego.

Dale Arrowhead Regional Medical Center
Dale at Arrowhead Regional Medical Center “Vigilance is written on his Forehead”

You see, when the staff had set the machine up for the next case and pushed the circuit onto the anesthesia machine it was done casually and not pushed on very tightly. With all of the drapes it was difficult to see where it came off. From this time on I started pushing the circuit on very tightly especially if someone else set the machine up. So this is one more item to add to the list; Make sure the circuit attached to the anesthesia machine is tight.

When people ask me about doing anesthesia the comment is often, “That must be really stressful all of the time, how do you handle that?” The answer is that most of the time giving an anesthetic does not seem to be unduly stressful but there are moments of controlled panic in-between moments of calm. So far in the course of my education and training there has been plenty of support with progressive responsibility given to the students. This has allowed us the opportunity to grow and learn by trying new things and rescuing ourselves from any little embarrassment that we get ourselves into. The safety checks and the protocols for giving anesthesia are fairly extensive but the best monitor is an alert attentive person at the helm with ‘Vigilance’ written all over their forehead.

Safety in anesthesia is a great subject. The AANA has a great resource for the pursuit of anesthetic safety at Anesthesia Patient Safety.com/ Another great resource is the Anesthesia Patient Safety Foundation whose mission …is to ensure that no patient shall be harmed by anesthesia.

The safety record in modern anesthesia is impressive. Yet where equipment and people are involved there is always the potential for trouble. To address that end I have enclosed a link to “Troubleshooting the Anesthesia Machine” by J. Jeff Andrews, M.D. which is interesting reading for the so inclined.

Categories : Anesthesia, Student Life

Comments

  1. dawnlang says:

    Great post even though that probably makes me a nerd. A good example of how we can overlook the little things. Glad to hear all was well. Great timing with the CRNA in with you, Murphy’s law.

    I’m probably borderline OCD with lists and checks and rechecks so I am hoping that will serve me well in the future.

    I really got to thinking the other day after posting here about what made me chose the anesthesia field. I’m sure that it has alot to do with the fact that the very first time that I had general anesthesia, I had somewhat of a partial awakening (for lack of knowing what else to call it). I’ll have to write a post on my blog about that sometime.

    It was many years ago ( 8-9 years), I went under general for a tubiligation and awoke in the recovery room (I’m assuming that’s where I was). I awoke mentally but was still physically paralized with intubation going. I was screaming in my head but nothing was coming out.
    When I fully came to, I told the nurses about my experience and they looked at me like I had lost my mind. In fact, I questioned numerous Dr’s about it and each time I was met with the same aloof attitude and got the feeling that I really was crazy or it was something that just wasn’t discussed. This was beofre the shows on the Discovery Health network.

    This experience stayed with me for a long time, I had nightmares about it and was terrified of ever having another surgery. Later, prior to another surgery a few years later, I questioned the anesthesiologist about my experience. She told me that I wasn’t crazy and those things do ocassinally happen. She was very reassuring and told me that I had received too much paralytic and not enough amnesiac inducing medication or that my body had metabolized the paralytic at a slower rate. That was the day that I learned what a CRNA was, she was not an anesthesiologist afterall but she had taken the most time with me and explained to me what had happened and made me feel at ease. I never again had a nightmare about my experience. I guess it was the unknown that had me so terrified but once I knew that there was a medical explanation I didn’t feel the need to fear it any longer.

    Wow, Sorry to take up so much room on your comments there David. Feel free to wipe it out once you’ve read it.

    Take care,
    Dawn

  2. KatieNP says:

    I’m a NP and recently had an ORIF with a CRNA performing the “anesthesia”…She was a very friendly nurse and great at the hand-holding but she worked unsupervised and let the sevo vaporizer run dry…To say that I was in a nightmarish situation because I didn’t have an anesthesiologist performing my anesthesia was an understatement.

  3. David says:

    What a crock of shit story are you trying to weave. Did you have awareness under anesthesia and how did you know that the vaporizer was dry? How did you know it was “sevo”? Your statements should be reserved for the court room and not here where the only agenda I hear is anti CRNA bullshit. If you want to see the latest real data check out this study that demonstrates CRNA safety head to head with any provider: Out Patient Study

  4. I personally think this particular blog post , “An Anesthesia Machine Ooooops
    :: Nurse Anesthetist”, particularly compelling plus the post ended up being a remarkable
    read. Thank you-Harvey

  5. David says:

    Harvey,

    Thank you and you are very welcome.

    David

  6. Hi David,

    GREAT post, and don’t mind that….person…above with their made up story. Keep doing your thing 🙂

    Jeff L.

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