From an outside perspective it looks easy: oxygen mask, propofol, PACU. What could possibly go wrong? Spoiler alert: Anesthesiology residency instilled in me a very healthy–and hard-won–respect for sedation cases. By Nabil Othman, MD
In my CA-2 year I encountered an elderly gentleman who needed an angiogram of his dialysis fistula. After starting the propofol infusion I placed an oral airway because his tongue obstructed his breathing by flipping back into his oropharynx. Easy first case. The surgeon was halfway done with the procedure. Then he started coughing. Easy fix. Remove the oral airway. He stopped breathing. I put it back in and gave more propofol. Then he stopped breathing. Now his oxygen saturation started dropping. I gave him a jaw thrust. No reaction.
His saturation dropped from 95% to 50%. Now the pulse oximeter was unreadable. I clumsily assembled the anesthesia circuit and tried to bag mask ventilate. I couldn’t ventilate him. As my heart rate skyrocketed to 150, my patient’s dropped to 20. At the last second my attending stepped in, turned a knob on the anesthesia machine, and bag-mask ventilated without a problem. After the patient was stabilized, I realized I didn’t remember to turn on the oxygen.
Once the patient was safety in PACU I knew I was in trouble. I almost killed someone. I reluctantly agreed to talk about the case. Rather than indulge himself in the verbal abuse common in medical education, my attending saw an important learning opportunity. We talked about different ways to airway emergencies in sedation cases, complications of IV anesthetics, and how to avoid dangerous situation before they occur. I resolved to be better next time. What more could I do?
Being a resident means balancing the expectation of perfection with the reality of learning medicine. Either I could spend my time wallowing in my mistakes or I could accept them as the price of becoming a physician. That day, my attending instilled more than knowledge of sedation cases. He instilled a culture of self-reflection, constructive criticism, and learning.
Two months later I faced a similar situation. My patient was a frail elderly lady receiving an angiogram of her lower leg. She wouldn’t stop moving–but would become apneic with minimal propofol and only 12.5 mcg of fentanyl. During the case I bag-mask ventilated her several times. This time I remembered to turn the oxygen knob! One of the times my attending walked in and saw me doing it. He laughed and said: “Very good! You are becoming more resourceful!” I weakly smiled back. He didn’t know what happened two months ago.
The more cases I did the more I saw how even routine cases can quickly become life-threatening. Sometimes sick patients have no complications and sometimes healthy patients have complications for no discernable reason. Anything can happen at any time.
Complications in sedation cases are rare, present in unexpected ways, and the cause is not always knowable. IV anesthetics affect every individual patient differently; the difference between appropriate anesthesia and apnea can be small or non-existent. When a complication occurs, you don’t have a breathing tube or invasive lines to help you. Emergency drugs and equipment may not be immediately available, especially in outpatient settings.
Keeping patients safe requires intense, diverse exposures to different patients, procedures, and anesthetics. This kind of focused practice is unique to residency training. Young medical school graduates practice medicine under the watchful eye of more experienced physicians. By the end of residency anesthesiologists learn how to recognize emergencies and intervene before their patient is harmed. In the operating room you don’t rise to the level of your expectations, you fall to the level of your training.
Since my first failure to rescue I have successfully managed all kinds of sedation complications. One example occurred in my fourth year of residency a middle-aged gentleman came in for an EGD. During the procedure he became stridorous and desaturated. I asked the gastroenterologist to remove the scope. Then I emergently intubated as his oxygen saturation became unmeasurable. After the case was over, I extubated uneventfully.
Eventually I became a teacher of junior residents, and I shared my experiences, mistakes, and lucky breaks with them. I pointed out the finer points of sedation cases, so they learned how to navigate uncertain situations. I want them to know how to recognize upper airway obstruction by looking at chest wall and abdominal movement. I want them to know how to select the appropriate IV anesthetics for patients with heart failure. I want them to know how to stay one step ahead of airway complications, just as I learned in my residency training.
See one, do one, teach one!
Nabil Othman, MD is an anesthesiologist in Los Angeles, California. He earned his bachelor’s degree in Biochemistry from Oakland University in Rochester, Michigan, followed by his medical degree at Wayne State University in Detroit, Michigan. Currently, he is in his final year of anesthesiology residency at Cedars Sinai Medical Center. After residency, he will complete a critical care fellowship at the Texas Heart Institute. When he is not an indentured servant in the hospital, he enjoys CrossFit, telling everyone he knows about CrossFit, and planning dangerous hikes in Hawaii with his college roommates. He blogs at http://www.airwaybagelcoffee.com.