A Budding Emergencist
Thursday, September 14, 2006
  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.


-The Emergencist

P.S. Yes I had a great time hyperlinking this post.
So what were his liver functions? And if his liver's poor synthetic function is thought to be the cause of the bleeding, why was the INR basically normal? Could be platlets, I suppose. More likely, being a drinker has just given him "PPP syndrome."

Piss-Poor Protoplasm.

BTW, in my experience in a large community hospital, the admitting docs generally do read the ER chart and tend to do a much more complete H&P than we do. This has a lot to do with the volume and time constraints in the ED.
i was going to say! you had link-a-thon on this one. that is sad though! no LFTs..ever? even in the ER? oy.
This comment has been removed by a blog administrator.

Aren't coags the last thing to go in terms of liver disease?

I don't know--let me look it up...

do do do do do...


Nah. High energy, Low Yield.


"Often a poor correlation exists between histologic findings and the clinical picture. Some patients with cirrhosis are completely asymptomatic and have a reasonably normal life expectancy. Other individuals have a multitude of the most severe symptoms of end-stage liver disease and have a limited chance for survival. Common signs and symptoms may stem from decreased hepatic synthetic function (eg, coagulopathy), decreased detoxification capabilities of the liver (eg, hepatic encephalopathy), or portal hypertension (eg, variceal bleeding)."

This pt is two for three--coagulopathy, decreased detoxification capabilities (long wake up derived from increased half life of mostly beta-eliminated anaesthetic drugs).

Yeah, I don't know the LFTs...it'll have to wait till monday. Nice thing about anaesthesia and other electives as an overpaid medical student--no weekends, no call.

My time will come--my friend in surgery regularly horrifies me with her tales from our quite malignant surgical service. Ex: she's gaga over having sunday off.

Yeah. No LFTs. Neuro services without residents are mostly (badly) run by PAs. Neuro PAs are a unique group--the grand canyon-sized gap in experience and knowledge between them and their attendings breeds a chip on their shoulders the size of Manhattan. I usually meet a neuro PA who I didn't like.

Furthermore, and this may be the seed of a future post--does anyone get the impression that most of the hazing/ego-tripping/pimping/idolatry that goes on on a service remains relatively confined to the attendings, residents, and students? The union status of almost everybody else ("allied health professionals") gives them a bye in the health care food chain. Viz: the only other person wearing a suit jacket on medicine rounds was an administrator, and he was reading the riot act to my attending, a Mud-Phud and a damn fine doctor...DURING ROUNDS! Of course, he was totally oblivious to how much he was rubbing our attendings' nose in the shit in front of his subordinates, but that breach of the social contract of academic medicine forever and irrevocably trivialized it for me. Maybe not such a bad thing.
Actually, coags are the *first* to go in terms of LFTs. One attending taught me that they're is the only actual liver FUNCTION test. The enzymes, etc. are cell breakdown products and only go up when there's anatomic damage.

Even though the INR was only 1.3, I wonder what the PTT was.
I'm just surprised that the ER didn't check LFTs on arrival......
I find it sad that one of your commentators chose to slam PAs, when I was linked to this post by Grand Rounds hosted by TheTundraPA, which is, in my mind, one of the best blogs about medicine and Alaska out there. IMHO.
"Bad Reaction to Anaesthesia?" is a very good post, thanks for sharing this information, I would like read more information about this!
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Emergency medicine, from the beginning of a new doctor's career.

Location: Big City, Metropolis, United States

Walk softly and carry a big vocabulary. Don't be inhuman. Find and greet God in every person you meet. The patient is the one with the disease. Do not get distracted. Charity begins at home. Do good and be happy. Don't just do something, stand still. Wear sunscreen. Don't get anyone pregnant, and don't go to jail, young man. Budget your luxuries first. You don't know what you don't know. People like learning, they just don't like being taught. When in doubt, go out. When life gives you lemons, make lemonade. Honey attracts more flies than vinegar.

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