Another Crazy Case

It seems that when the weather is hot, the crazy cases come in to the OR. That was certainly the case the other night. The following night may not have been weather related, but it is definitely one for the books. I was covering the night shift in the cardiovascular ICU (CVICU). My friend, another anesthesiology resident, we shall call him Jason, was covering Labor and Delivery. After a late night c-section, he came over to partake in the festivities of the CVICU, where we were having a going away party for one of the nurses. While we were snacking on chips and dip, the charge nurse came up to us and told us about a transfer. (Disclaimer: the following facts have been altered to protect the privacy of those involved). "We are getting a 30 year old pregnant lady, 34 weeks along, with an aortic dissection (this is what John Ritter and Lucille Ball died of). She's coming from Saint Elsewhere Hospital. The cardiothoracic surgeon is on his way to the ER to meet her." Yikes. These could be medically managed if the tear is not too bad, or they need to be surgically repaired if the tear is bad. We waited for news from the surgeon of whether we needed to go to the OR or not. In the meantime, Jason and I were lightheartedly arguing about who should do this case.

ME: You are covering OB. If they need to repair the aorta, they will probably have to take the baby first (c-section). This is your case.


JASON: No way. Even if they do the section first, they will do it in the CVOR (cardiovascular OR), not the OB OR. So it's your case.

We continued to banter back and forth, when we heard that dreaded overhead page:

"ANESTHESIA STAT . . . EMERGENCY ROOM. ANESTHESIA STAT . . . EMERGENCY ROOM."


I don't think I have ever seen Jason move so fast. We booked it over to the ER. There in the trauma bay was the pregnant lady laying on the trauma table, panting, "I can't breathe. I can't breathe." I saw the attending anesthesiologist, who quickly updated me: "They need to section her now." While the OB team was prepping and draping her belly, I whispered to the patient, "We are going to give you some medicine to go to sleep. Then we will help you breathe. Try to take some slow, deep breaths. We are going to take good care of you and your baby."

20 of etomidate, 60 of sux. 6.0 tube. We don't have one? Okay find me the smallest tube you've got. Do we have suction? Hold cricoid. Give the meds. Okay she's asleep. Go ahead and cut. We intubated her as the baby was being delivered. There was no crying. Just a blue baby. The NICU team quickly retrieved the baby from the OB team and resuscitated the baby. Meanwhile we continued to take care of mom. Right internal jugular cordis. Right radial arterial line. Bilateral radial pulses. We'll probably need a femoral a-line, as well. Blood transfusions, fluids wide open. The OB team sutured her up, then we were off to the CVOR to fix her tearing aorta. To do that, we had to place her on the cardiopulmonary bypass machine. When the surgeon opened her chest, about 4 liters of blood filled the cavity. We continued to transfuse her. We used a transesophageal echo probe (TEE probe) to examine her heart from within. Sure enough, there was the tear. The surgeon fixed it, we came off pump, and the patient was wheeled to the CVICU. So far she and baby are doing okay. Not quite out of the woods, however.

Another adrenaline-filled, heart pumping case. Apparently, this is not the first case of this. Scary, no? I forgot to mention that this was the night after the shooting victim from my previous post. The black cloud has returned.