Bad Reaction to Anaesthesia?
I page the attending anaesthesiologist.

"Hello, Dr. H? The patient is in the room."

"Already? Ok, fine."

At this point, I'd already seen the patient with the resident (the REAL resident, not me the fake resident. The morning lecturer had referenced a clarification about autotranfusion postpartum I had asked for after her previous week's OB gas lecture, noting that "the medical student" had made a good point. I'm still a little raw about it.) I'd already gone through the history, a s/p posterior cervical laminectomy for numbness/weakness/paresthesias in fingers and toes the day before. The resident and I had already "lined-up" the patient with EKG, 02 sat, BP cuff, 3L nasal cannula, and transferred him to the operating table. All was left was to paralyze him, intubate him, and position him to the neurosurgeons preference. An emergent surgery for acute epidural hematoma.

Curiously, the patient had also developed b/l DVTs between admission and , so for an unexplained reason they had already put a greenfield filter in--as medical management is the standard of care, however, perhaps they had already anticipated the current complication which contraindicates anticoagulation --epidural hematoma. However, the complication had already occurred? Why?

This line of questioning had lead me to investigate lab values--INR 1.3--a little high. Why? No coumadin on board. No record of heparinization. Also no LFTs. Ah.

My curiosity is piqued. How does a patient with an obvious bleeding diasthesis go for a week in the hosptial without liver function tests? I can only assume neurosurgical oversight. Reminds me of an old joke:

An intern and a crusty old attending were rounding the corner to the elevator when the attending spied one going their way. Moving with a speed heretofore unsuspected by the intern, the attending just manages to wedge his hand in between the elevator door and the jamb, whereupon it opens. The intern gasps, "Doctor! You could've lost a hand!" The salty old medicine attending replied with a shrug, "Well, I'm an internal medicine doctor. I don't really need my hands anyway!" The intern ponders this significantly as the doors begin to close again. The intern glances up and sees a surgical resident dashing towards the elevator door. Just as the door is closing, the surgical resident sticks his head in between the closing door and the jamb.

So anyway, I mention the probable liver disease in this 65 year old man. "Ah well," he says, "it doesn't matter anyway." "But won't it make the patient harder to wake up? I mean, we should reduce the dose of anesthesia." "Nah."

Not surprisingly to me, the patient took a full half hour to wake up and be extubated. I looked ruefully at the drainage bag from the posterior cervical incision site, draining almost 500cc of bright red blood (an indication of poor clotting, another indicator of severe liver disease) by the time we got to the recovery room.

This patient came in without a primary care doctor. I think this is the reason why he got such shoddy care ( = ignorance of liver function status.) If an intern in a normally hypervigilant and over-testing-prone teaching hospital can spot a failure of care, it's bad.

On the ER note of this respectable, employed, family-oriented grandfather?

"Alcohol use: 3+ drinks of hard liqour per day x 30 years."

Nobody reads the ER chart.

Sigh.

-The Emergencist

P.S. Yes I had a great time hyperlinking this post.  ¶ 9:14 PM