Tag Archives: Taxi

A weekend of work

After Thanksgiving Day off, cousin Steve dropped me off at the Wallingford train station where I caught the SEPTA train in to Market East Station and crossed the street to the bus station to catch my Greyhound Coach d’Elegance back to Manhattan.  As fellow passengers were boarding, the Indian woman behind me complained when I reclined my seat back a few inches.  “Oh, oh, please raise your seat, my knees are hurting!”  Irritated that a woman who couldn’t be taller than 5’4″ was complaining about her knees to someone a full foot taller than her, and resisting the urge to suggest she could pick out a different seat on the bus–preferably behind an unoccupied seat–I raised my seat a couple inches and rode the rest of the trip with this semi-comfortable compromise.

I took my first pediatric anesthesia long call on Friday.  I went in expecting to anesthetize a three-day-old neonate for a Norwood procedure (palliative surgery for hypoplastic left heart syndrome), only to find out the case was cancelled.  Instead I did a central line on a 1 year old and a pyloromyotomy on a 3 week-old, before helping with sedation for a 7 year-old in the MRI.  This child had “single ventricle physiology” having a hypoplastic left heart as well, now having undergone the Norwood, bidirectional Glenn, and Fontan procedures.

I then did brief afternoon rounds with the pediatric pain attending, as I was covering the “OUCH” pager that night.  Circling through the list before I left the hospital, everyone seemed comfortable enough, and I went home.  This is one of the few rotations where we can take home call, or “pager call.”

I was awakened by my pager at 0100.  There was a 7 year old with a ruptured eyeball, and the ophthalmologists wanted to take him to the operating room within the hour.  I quickly paged my attending to notify her of the case, dressed, and caught a cab to the hospital.  No telling how long I would have waited for the subway at that hour, and ten dollars seemed like a small price to pay to avoid the cold and get there quickly.

I was in scrubs and had the room set up by 0150. but the patient didn’t show up till nearly 0300 from the emergency room!  Somebody felt the need to order a CT scan before sending him up to the operating room.  Anesthetic concerns include the following:

  • This is a trauma, and thus may put the child at risk for aspiration of stomach contents during induction of anesthesia.  Pain and increased tone from the sympathetic nervous system delays gastric emptying, and aspiration can occur as a patient is anesthetized and loses protective airway reflexes.  Aspiration, though rare, has a high fatality.  In order to minimize the risk of aspiration, anesthesiologists frequently employ the “rapid sequence induction” technique.  This involves ample preoxygenation of the patient to build up as large a reserve of oxygen as possible in the lungs, and a quick administration of a sedative and a paralytic–usually succinylcholine because of its rapid onset.  As the medications are pushed, pressure is applied to the round cricoid cartilage in the neck to help close off the esophagus.  This pressure is continued until the placement of the breathing tube is confirmed.  The breathing tube with its inflatable cuff protects the lungs from aspiration.  In this case, the child had not eaten for more than 12 hours, so this risk was probably lower.
  • The eyeball (or “globe” in medical terms) is ruptured.  Succinylcholine can increase intraocular pressure, which could lead to greater extrusion of contents from the eye.  Most anesthesiologists get the willies when we think about jelly-like substances squirting out of an eye wound, so we prefer to avoid this.  Additionally, succinylcholine is avoided in children because of the risk of malignant hyperthermia (serious adverse reaction) in a child with an undiagnosed myopathy (muscle disorder).  Hence, we used rocuronium for our paralytic agent with an onset nearly as fast.
  • General anesthesia, and eyeball surgery in particular, can cause nausea, and wretching can increase pressures in the eye.  We would like to avoid this post-operatively as it could damage the surgical repair, so administering ondansetron (a powerful anti-emetic commonly used for severe gestational nausea or chemotherapy-related nausea) is a must.
  • Coughing and bucking on the endotracheal tube as a patient emerges from anesthesia is also suboptimal for the same reason.  We can treat patients with intravenous opioids and lidocaine to blunt airway reflexes, and we could topicalize the vocal cords with lidocaine, but in this case we opted for “deep extubation.”  This is a technique in which the patient is allowed to resume spontaneous ventilation, and the endotracheal tube is removed while the the patient is still anesthetized.  The airway is then supported and supplemental oxygen provided.  This provides for smoother wake-ups.

It was around 0600 when I dropped off the patient in the recovery room, leaving me enought time to check e-mail and change into street clothes before heading uptown for my moonlighting shift which began at 0700.  Thankfully, the day was as slow as it could be (not a single operating room case, epidural, cesarian section, or stat intubation) which meant I didn’t do much other than sleep, eat, and read.

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Getaway car

My friends Dennis and Susanna got married recently.  Here’s a cute picture of Susanna peeking out the window of the getaway taxi.

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Enjoying New York in the spring

I’ve realized that there are many ways Pain Clinic could run smoother.  Having an additional exam room would facilitate patient flow.  Stocking reflex hammers in every room would also help.  But most notably, having a fifth of Jameson Irish Whiskey in the back room would greatly lubricate the process.  Made from fine ripe barley, flavor-rich malt, and crystal clear water from the green mountains surrounding Dublin, a sip of that smooth drink between patient encounters (or even stepping out during a patient encounter) would greatly improve one’s outlook on the day.

Such was the morning yesterday.  In the afternoon, I got to see several pain procedures, including epidural steroid injection, cryoablation of the occipital nerve, and medial branch blocks of cervical nerves.  Lecture in the afternoon with all the other CA-2s focused ostensibly on reviewing the medical literature, but the real take-home message was secrets to advancing one’s career in an academic instutition.  (“What I’m telling you does not leave this room…”)

In the afternoon, I planned to meet up with Gloria to check out the free museums along Fifth Avenue.  I rode the subway to 103rd Street, and as I realized there was no crosstown bus nearby, the words of a very wise New Yorker flitted through my head.  “Living in New York City is all about being separated from your time or your money.  You can have your time, or you can have your money, but not both.”  This sage advice has proven true on countless occasions.  Generally I err on the side of saving money, but to successfully cope with life here, one must be prepared to part with either in certain circumstances.  With my dress shoes, slacks, tie, tired feet, and shoulder bag, this was one such occasion.  $10 and 10 minutes later, the cab deposited me on the Upper East Side in the shadow of the stately buildings that line Fifth Avenue…

…however, not before nearly running over a woman with her stroller crossing 96th Street at Central Park West.  True, we did have a protected left turn, but it’s understandable that pedestrians instinctively start to cross when traffic comes to a stop the opposite direction.  My driver seemed to make no effort to slow down, and as we whizzed by within feet of the stroller, he rolled down the window and shouted at the woman!  To that woman who was crossing 96th Street at Central Park West at 6:15 PM on Tuesday, June 3, 2008, and to her now traumatized infant in the green stroller: I am sorry.

Nine museums along Fifth Avenue offered free admission that evening, and the avenue was closed off to give a festival sort of feel.  We checked out the Museum of the City of New York, which had fascinating displays featuring New York City homes’ interiors through the centuries and the role of the Port and waterfront in commerce, trade, industry, and leisure.  We finished the tour in front of the museum, watching a choir from Harlem called Impact perform songs and dance.  The group had been featured in last year’s movie August Rush.

All in all, not a bad day.

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Filed under Around town, Musings, Work