A HURRIED SURGEON CAN HARM A PATIENT

A 16 year old boy was posted for removal of ureteric stone on his left side . A patient of ASA—I without any known problem. The stone was of small size was said to be close to ureteric  opening to bladder.

The patient was given spinal anaesthesia in sitting position with a 25 G needle a dose of 2 ml ( 10 mg ) bupivicaine  Heavy with the idea that the procedure will be over quickly.

The patient was positioned lithotomy and the surgeon proceeded  after 10 mins of anaesthesia after sterilization   draping the legs etc etc .

Some how the procedure was difficult . The ureteric orifice could not be located and identified. After what was thought to be ureteric orricie the instrument could not be negotiated . The surgeon was struggling there for more than 90 mins when he decided to remove the stone  by oprn method.

The patient was repositioned .

While I was preparing the drugs for induction of anaesthesia  and setting up the Laryngoscope tube etc, surgeon hurried applied betadine antiseptic and draping  . Without any check put an incision slightly obliquely above the inguinal region  for an extraperitonial  approach.

Suddenly the patient gave a cry and moved all his body with a convulsive  movement for anout 10—15 seconds. The drape the pulse oxymetre probe came off and the saline stand fell down. While we were looking at those things and fixing the ECG leads and probe etc the patient was found to be quite and unresponsive . The pulse  in oxymetre probe was absent . When radial pulse was palpated , there was nopulse. Cardiac arrest has occurred. The assistant was asked to prepare an adrenaline injection  diluted to 10 ml. Cardiac massage was started with a thump on his chest.

Simultaneously Obygen mask was applied to face and two breaths was delivered. With that the heart beat returned and radial pulae was felt. Afetr about another 10 seconds the respiratory activity returned  when the patient was intubated with a small dose of Midazolam 2 mg . After observing the vital parameters for next 15 mins. Aditional doses of Ketamine 25 mg, Analgesic fortwin 15 mg was administered followed by muscle relaxant Nitrous oxide was added and the surgeon was asked to proceed .

The surgeon now proceeded more carefully and it was all over in another 45 mins.

The patient was reversed as usual and had a complete recovery without any neurologic problem

FB in trachea

A 20 year old male son of a doctor presented with #nasal bone for fixation. Or of ASA-I the procedure was completed with GA with atropin thiopentone scholine vecuron. Elevation of #pieces done with with an external application of plaster. A nasal pack was given to both nostrils individually. Tongue tie was applied to prevent fall of tongue and easy mouth breathing. Anesth  was reversed and after satisfactory recovery , sent to ward. 15-20 mins later emergency call was given for the patient had difficulty in breathing and cyanosis.

  The  patient was attended within minutes .The pattern of respiration indicated acute airway obstruction with severe indrawing of chest wall. The pt was cyanotic and unresponsive. The patient was intubated on the ward bed. While trying to ventilate with an Ambu there was much resistance and not knowing what to do brought the patient to OT  . Connected to anaesthesia machine but still not possible to ventilated.  The pulse oxymeter could not  show any pulse.. I could feel the patient has arrested and lying flaccid. The ET tube wasRemoved and  tried to visualise what was in trachea. With flaccid and wide open glottic opening, I could see something whitish deep down the trachea. That object was beyond the reach of Maggils forceps. Fortunately   a long foreign body forceps was available with that I could catch the whitish object. Lo it was one of the nasal pack.. (picture below). The father a doctor who was present in OT collapsed on the floor with vasovagal attack Pt was  reintubated a few cardiac massage and a thump on the chest wall the heart activity returned and  within 20 mins the patient regained full consciousness.Pt was treated for possible hypoxic brain injury. The patient recovered completely without any residual damage.

                               

pICTURE OF FOREIGN BODY