20-something year old primip came today with preeclampsia and was deemed a c/s candidate for her 26 week baby. She was 5’8″, 165lb and had no prior issue with previous surgeries. She was started on magnesium preop. The mag was held intraoperatively and would resume postoperatively. Pt was in sitting position for her spinal, which was placed at L4-5. Good clear CSF return. 0.75% bupi dosed at 13.5 mg with intrathecal fentanyl 15mcg and intrathecal morphine 0.2mg. BP decreased from 150s to 130s, which was appropriate. Patient stated she had increased tingling and decreased mobility in her legs. All symptoms and signs appropriate with her spinal. Patient passed the Allis clamp test prior to incision. She was quite anxious: propofol was given IV for anxiolysis. Patient was adamant about breastfeeding/pumping for her baby. No complications with delivery. Uterus was externalized and patient was sensitive to pressure and tugging/manipulation. IV fenatnyl and IV morphine were given along with IV propofol. When uterus was internalized, patient felt more pressure that seemed unbearable. More IV pain meds were given. Suggestion was made for intraperitoneal chloroprocaine. Patient able to tolerate fascial closure as well as staple skin closure.
Now that my oldest is almost 4 years old and my youngest is almost 3… it’s a good time to reflect back on my time during pregnancy, post-partum, breastfeeding, maternal/family leave, full-time work, and raising 2 toddlers.
Pregnancy really was a wonderful time. Aside from the GERD, waddles, having to pee all the time and drinking a ton of water… it was wonderful feeling the little kicks and getting the attention of people to always help me (open a door, lift things, walk with me, etc.). I worked up until I went into labor… literally.
Hours worked baby #1Hours Worked Baby #2
The most difficult things to do during MY pregnancy: make appointments, drink enough water, peeing every 2 hours (even during the night), eating (I could only take 4-5 bites before getting full), sleep.
Post-Partum
No one tells you what to expect post-partum. It’s a rude awakening when it’s really difficult to have a BM, wipe, breastfeed, wake up, and think clearly. For me, the SI joint pain from pregnancy lingered on even until today. Bonding with baby is unique and special. It was a wonderful time to watch my babies explore their senses. Sleep and breastfeeding: It’s really tough to get in enough sleep and breastfeed constantly. But after 2 weeks, breastfeeding got better for me. Maybe I was lucky. Sleep got better for me after 2 months After the 2nd kiddo, I think I had a bit of postpartum depression. Coupling the lack of sleep while also trying to be present for a 13-month old really wore me down. I was in a really dark place: the thoughts, the lack of care of harm to myself, the total loss of happiness for things I previously enjoyed. It was all very real, very memorable, and something that I look back on with sadness bc I wasn’t my best for the kids, my hubs, or myself. I’m thankful to have moved beyond that. The Peloton saved me on this one. I told NO ONE.
Breastfeeding:
Rent a hospital-grade breast pump prior to leaving the hospital. Visit with the lactation consultant while at the hospital to really learn how everything works. I was lucky to have a great LC for both deliveries. The first one really encouraged me and taught me good technique. The second was fabulous as she supported me and encouraged my efforts while also allowing me to opt for normalcy and not beat myself up if my milk production wasn’t 100%. Both excellent teachers and perspectives. Breastfeeding is new and it’s hard. Get help early and often! When you come back to work, do what you can. I oftentimes pumped in the OR and immediately put my stash in the freezer during breaks. This became really tough for me as breaks are uncertain and you don’t want to burden people who also need breaks. My milk supply went down fast, but I did what I could and that was my best. Don’t beat yourself up.
Maternal/Family Leave:
I was really lucky to be able to have 3 months off work. My anesthesia group was absolutely wonderful in allowing bonding time. I took the full 3 months. My husband then took his 1 month and we were able to do a solid bond with the kiddos for 4 months and then put them into daycare when they were 5 months old. Would it be great if we had full pay for 1 year of maternal/family leave? Yes. But, in the US, this is the best I could get and I’m grateful for it!
Full-time Work:
This was my own decision to continue working full-time. You can see in the charts above. After my second baby, I came back and still worked full-time. This was a personal choice. Kids are innocently demanding…. so is my job. I don’t really know how to find that right balance just yet. I miss out on my babies, and I miss out on work. In the end, you have to be ok with not being the best at everything. You will make sacrifices and you will feel awful. It was be a gut punch that you readied yourself for, but still feel every ounce of hurt when you miss things. The first tuck-in, the first goodnight kiss, the many goodbyes, the bathtime shenanigans, the sweet baby smells…. you will miss them. It gets easier. But, it still hurts when you miss these things. It’s almost like life moves on without you. That is…. until you get back and see the smiles and feel the hugs and kisses from them.
Raising 2 toddlers 13 months apart:
This is something! We brought home our second baby just after our 1st baby turned a year old. I don’t think the concept of a sibling coming to the house was even a concept that a one year old can grasp. Having two kids so close in age, but at different stages of development was REALLY HARD. They are just now starting to play together and sharing appropriately. It is still hard for us despite both kiddos being potty-trained (nighttime diapers only for my sanity). Everyone says 5 years old is the magical age where things get easier. We’re almost there!
During the delivery of our 2nd kiddos, I had a moment of weakness and thought a third child would be great. The second delivery was significantly easier than the first. Perhaps my body and mind were playing tricks on me. We feel complete. We have two beautiful and healthy kids. We couldn’t ask for more.
I was shocked to see that the NHS could ban surgery for the obese and smokers. That’s socialized medicine. You take a conglomerate group of people (the UK) on a limited budget for healthcare… and basically find the cheapest most cost-effective way to deliver healthcare. But in a way, it’s empowering patients to take responsibility for their own health. Smoking, for sure — I agree 100% that surgery should be banned for this population. Obesity is a bit trickier — there’s genetics and environmental factors at play in this one. I don’t think anyone chooses to be obese. But, people do have the power to change their eating and exercise habits. Despite these efforts, there are some people who are still obese…. and these people should not be faulted.
Why single out the obese and smokers?
From SlideShare
From SlideShare
From TobaccoFreeLife.org
Smokers and the obese have elevated surgical risk and mortality, which means more cost to treat and hospitalize and provide ongoing care.
From HealthStats
I think the NHS is on to something here. They’re opening doors to moving the liability and responsibility away from physicians and towards patients. This is a plus. Outsiders may see it as separatism and elitist to only provide care for people who are healthy. But look at the facts and the data…. obesity has a lot of co-morbidities associated. Smoking has a lot of co-morbidities associated as well. Why should physicians be penalized for re-admissions, poor wound healing, longer hospitalizations when the underlying conditions themselves are already challenging enough? In fact, I would urge insurance companies to provide incentives to patients/the insured with discounted rates for good and maintained health and wellness. With all the technologies, medications, and information out there, it’s time patients take responsibility for their own health. I take responsibility for mine — watching my diet, exercising, working on getting enough rest, maintaining activities to keep my mind and body engaged, meditating for rest and relaxation. It’s not easy, but my health is 100% my responsibility. I refuse to pass the buck to my husband, my family, my physician, etc. I do what I can to optimize my health and future — and if that doesn’t work… I call for backup.
Patients need to change their mindset re: health. It is not your spouse’s responsibility to track your meds. It is your responsibility to know your medical conditions and surgical history. The single most important (and thoughtful) thing a patient can do is keep an up-to-date list of medications, past/current medical history, surgical history, and allergies to bring to every doctor’s appointment and surgery. This helps streamline and bring to the forefront your conditions and how these will interplay with your medical and surgical plan and postoperative care. Please do not forget recreational drugs, smoking habit, and drinking habit in this list. It is very important to know all of these things. Also, your emotional history is very important. Depression, anxiety, failure to cope, etc. This all helps tie in your current living situation with stressors and your medical history.
Links for educating yourself in taking responsibility for your health:
It seems like in today’s day and age, emergencies are occurring everywhere. From hurricanes to shooters to earthquakes and fires… I think it’s always important to know what to do. Here are some fabulous checklists I’ve found for getting through those emergencies. These are not substitutions for knowledge and training. Clinical judgement warranted.
The WordPress.com stats helper monkeys prepared a 2015 annual report for this blog.
Here’s an excerpt:
A San Francisco cable car holds 60 people. This blog was viewed about 2,000 times in 2015. If it were a cable car, it would take about 33 trips to carry that many people.
Lately, I’ve been changing my regimen for pain control with PCEA. It seems most of my partners use a 10ml/hr basal rate, 5ml bolus dose, 10 minute lockout, and 30 ml/hr max.
My current strategy for PCEA (0.0625% bupi + 2mcg/ml fentanyl):
Over the years, I’ve been asked to inject various dyes to help light up the urine for visualization of the ureters. Now, we’ve moved to fluorescein because it “lights up” quicker than other previous dyes. Why are we always switching? Drug shortages.
These aren’t my own thought, however, I can easily agree with the list below. One of the things that was left off this list was pediatric hearts. I had the chance to do a one month pediatric cardiac anesthesia rotation at a very busy Children’s hospital and it was definitely an eye opening experience. Teeny tiny babies. Itty bity tubes and IVs. The heart plumbing/circuitry was anything but normal. I have the utmost respect for pediatric cardiac anesthesiologists — and that’s coming from an adult cardiac anesthesiologist.
TOP 10 MOST STRESSFUL SITUATIONS IN AN ANESTHESIOLOGIST’S JOB
Emergency general anesthesia in a morbidly obese patient. Picture a 350-pound man with a bellyful of beer and pizza, who needs an emergency general anesthetic. When a patient with a Body Mass Index (BMI) > 40 needs to be put to sleep urgently, it’s dangerous. Oxygen reserves are low in a morbidly obese patient, and if the anesthesiologist is unable to place an endotracheal tube safely, there’s a genuine risk of hypoxic brain damage or cardiac arrest within minutes.
Liver transplantation. Picture a patient ill with cirrhosis and end-stage-liver-failure who needs a complex 10 to 20-hour-long abdominal surgery, a surgery whichfrequently demands massive transfusion equal to one blood volume (5 liters) or more. These cases are maximally stressful in both intensity and duration.
An emergency Cesarean section under general anesthesia in the wee hours of the morning. Picture a 3 a.m. emergency general anesthetic on a pregnant woman whose fetus is having cardiac decelerations (a risky slow heart rate pattern). The anesthesiologist needs to get the woman to sleep within minutes so the baby can be delivered by the obstetrician. Pregnant women have full stomachs and can have difficult airway because of weight changes and body habitus changes of term pregnancy. If the anesthesiologist mismanages the airway during emergency induction of anesthesia, both the mother and the child’s life are in danger from lack of oxygen within minutes.
Acute epiglottitis in a child. Picture an 11-month-old boy crowing for every strained breath because the infection of acute epiglottis has caused swelling of his upper airway passage. These children arrive at the Emergency Room lethargic, gasping for breath, and turning blue. Safe anesthetic management requires urgently anesthetizing the child with inhaled sevoflurane, inserting an intravenous line, and placing a tracheal breathing tube before the child’s airway shuts down. A head and neck surgeon must be present to perform an emergency tracheostomy should the airway management by the anesthesiologist fails.
Any emergency surgery on a newborn baby. Picture a one-pound newborn premature infant with a congenital defect that is a threat to his or her life. This defect may be a diaphragmatic hernia (the child’s intestines are herniated into the chest), an omphalocele (the child’s intestines are protruding from the anterior abdominal wall, spina bifida (a sac connected to the child’s spinal cord canal is open the air through a defect in the back), or a severe congenital heart disorder such as a transposition of the great vessels (the major blood vessels: the aorta, the vena cavas and the pulmonary artery, are attached to the heart in the wrong locations). Anesthetizing a patient this small for surgeries this big requires the utmost in skill and nerve.
Acute anaphylaxis. Picture a patient’s blood pressure suddenly dropping to near zero and their airway passages constricting in a severe acute asthmatic attack. Immediate diagnosis is paramount, because intravenous epinephrine therapy will reverse most anaphylactic insults, and no other treatment is likely to be effective.
Malignant Hyperthermia. Picture an emergency where an anesthetized patient’s temperature unexpectedly rises to over 104 degrees Fahrenheit due to hypermetabolic acidotic chemical changes in the patient’s skeletal muscles. The disease requires rapid diagnosis and treatment with the antidote dantrolene, as well as acute medical measures to decrease temperature, acidosis, and high blood potassium levels which can otherwise be fatal.
An intraoperative myocardial infarction (heart attack). Picture an anesthetized 60-year-old patient who develops a sudden drop in their blood pressure due to failed pumping of their heart. This can occur because of an occluded coronary artery or a severe abnormal rhythm of their heart. Otherwise known as cardiogenic shock, this syndrome can lead to cardiac arrest unless the heart is supported with the precise correct amount of medications to increase the pumping function or improve the arrhythmia.
Any massive trauma patient with injuries both to their airway and to their major vessels. Picture a motorcycle accident victim with a bloodied, smashed-in face and a blood pressure of near zero due to hemorrhage. The placement of an airway tube can be extremely difficult because of the altered anatomy of the head and neck, and the management of the circulation is urgent because of the empty heart and great vessels secondary to acute bleeding.
The syndrome of “can’t intubate, can’t ventilate.” You’re the anesthesiologist. Picture any patient to whom you’ve just induced anesthesia, and your attempt to insert the tracheal breathing tube is impossible due to the patient’s anatomy. Next you attempt to ventilate oxygen into the patient’s lungs via a mask and bag, and you discover that you are unable to ventilate any adequate amount of oxygen. The beep-beep-beep of the oxygen saturation monitor is registering progressively lower notes, and the oximeter alarms as the patient’s oxygen saturation drops below 90%. If repeated attempts at intubation and ventilation fail and the patient’s oxygen saturation drops below 85-90% and remains low, the patient will incur hypoxic brain damage within 3 – 5 minutes. This situation is the worst-case scenario that every anesthesia professional must avoid if possible. If it does occur, the anesthesia professional or a surgical colleague must be ready and prepared to insert a surgical airway (cricothyroidotomy or tracheostomy) into the neck before enough time passes to cause irreversible brain damage.
Sleepy Time 