Turn the calendar back to 2003, and I’m in my fifteenth year in a busy fee for service practice in New Mexico in a 160-bed institution that has two CRNA groups and no anesthesiologists.  I have one partner and am taking call every other day and weekend, which includes a busy OB and labor epidural service.  I haven’t taken more than ten days in a row off during the fifteen years, and I’m feeling very tired.  Little did I know how my life was about to change.  I had always been healthy with no hospitalizations, serious illnesses, or identifiable risk factors, but I had noticed a small abdominal mass that seemed to be enlarging rapidly.  I cornered one of the general surgeons I know, like, and trust and asked him to do an exam.  A CT scan the following day was read by the radiologist as probable sarcoma.  The following Monday I was on the schedule for an exploratory laparotomy.  

I am scheduled to follow cases that were scheduled earlier and arrive in the holding area early in the afternoon.  Natalie, a good friend of mine and a PACU nurse, started my IV and John, CRNA, had my epidural in place quickly and painlessly.  I am very calm knowing I have a surgeon and CRNA I trust, and I decline offers for sedation.  

The procedure was long and tedious and I was transfused four units of blood before the four and a half pound mass was removed.

The only things I remember are moving to the OR table and waking in PACU.  I had no awareness during the surgery, but I must have been distracted since I missed the perfect opportunity to play a practical joke on John by telling him I was awake.

After several weeks and numerous pathologists from several institutions examining the specimen I was diagnosed with large cell lymphoma. This was good news since it is much more responsive to treatment than a sarcoma.  

Two weeks later I have my first chemotherapy treatment, which seems to go well.  Over the next two weeks my weight has dropped from 190 to 158, and I cannot eat. I am admitted and started on peripheral TPN.   I am eventually diagnosed with a small bowel obstruction from ischemic fibrosis, but the surgery has to wait because my white count is 200, and I am told the mortality risk is 50%.  One week later I am back in the OR to have twelve inches of small bowel removed followed one week later by more chemotherapy.  

The chemotherapy treatments continue for six months. and I return to my practice seven months later and within a month am taking call every other day and weekend again.  Eighteen months later my priorities are different, and I decide to retire at 52 even though my pet scans are normal, and I am feeling great.  

After about six months I start thinking I might like to practice again.  From the age of nineteen my only professional goal was to be a CRNA and practice independently.  Suddenly, sitting around and playing tennis almost every day, even if it was in the southern Rocky Mountains, was not enough after having such a passion for my profession for so many years.

After searching for a few months I accepted a twenty-four weeks a year position which is my current practice.  

Back to Monday morning and my scheduled cases.  I believe the total knee arthroplasty and rotator cuff repair patients would benefit from a continuous nerve block infusion.  However, there is a problem.  I only have one tray because of an unexpected delay in delivery of an order that was placed several days ago.  I decide to place a catheter in the total knee patient and do a single shot interscalene block for the shoulder case.  Normally, I would do a continuous cervical paravertebral block for the shoulder case.  My decision to do the catheter technique for the knee is based on the relatively short duration of single shot lumbar plexus blocks.  It is unusual to have duration of greater than six hours even with ropivicaine or bupivicaine.  

My usual routine is to review the patient’s chart and telephone them to obtain a verbal history and explain their options for anesthesia and post operative pain management.  I am unable to contact the first patient and talk to him for the first time in the outpatient department.  After discussion including the risks and benefits of regional and or general anesthesia the patient accepts my recommendation for a combined technique consisting of continuous lumbar plexus block, spinal anesthesia and IV sedation.  The lumbar plexus catheter will be used for intraoperative anesthesia and postoperative analgesia.  The spinal insures a rapid onset and will prevent the possibility of the patient moving the non-operative leg during the surgery.  

The patient is then transferred to the operating room and standard monitors are applied.  The remainder of the case was managed with moderate doses of IV sedation.  A lumbar plexus infusion of 0.2% ropivacaine 8 ml per hour with a demand dose of 5 ml Q 30 minutes PRN was started in PACU.  

I did have the opportunity to talk with the patient scheduled for a rotator cuff repair by phone and he was expecting to receive a continuous nerve block combined with a general anesthetic.  I did many shoulder cases with interscalene block and IV sedation in years past with a couple of surgeons who did not use the beach chair position.  However, with the beach chair position I prefer to combine with general anesthesia and an LMA in place because access to the airway is restricted.  

I explain to the patient he will have a single shot interscalene block instead of the catheter technique because of the unavailability of the supplies I needed.  He understands and agrees to proceed.  The patient received 1 mg of midazolam in the outpatient department and an additional 2 mg before initiating the block.  The landmarks are easily palpated and the neck is prepped. A skin wheal is raised with 0.5 % lidocaine. The nerve stimulator is set at 0.8 mA and a 22g X 5 cm insulated needle is advanced at the C7 level.  A twitch in the arm is quickly obtained and the stimulator setting is reduced to 0.5 mA.  40 ml of 0.75% ropivacaine is injected by an assistant in 5 ml increments with aspiration after each incremental injection. The ropivacaine dosage is higher than recommended, but, based upon previous experience, will significantly increase the duration of the block.

The patient is transferred to the operating room and standard monitors were applied.  Induction of general anesthesia was accomplished with propofol and a size 5 ProSeal LMA was inserted. Spontaneous respiration was maintained with 1.2 % sevoflurane.  The patient did not require additional anesthesia or analgesia for the surgical procedure.  

The patient was discharged approximately two hours after the completion of the surgery with an arm sling and was given detailed postoperative peripheral nerve block instructions and precautions.

I make a quick trip to the outpatient department to see the next patient who is scheduled for a colonoscopy.  The patient is in the endoscopy room within a few minutes.  I rarely use anything other than propofol for this procedure.  A few minutes later the patient is awake and being transferred back to the outpatient department and I am on my way to the floor to visit the patient who had the total knee replacement.  He is doing well and has no complaints.

Next for me are the seemingly never-ending tasks that go along with practice in a small rural hospital.  Cleaning, ordering, stocking, coding, inventory and an endless loop of paperwork are always waiting.  

This is a typical day in my life and I am eternally grateful to be part of the nurse anesthesia profession.

 

Don Elswick