So, I've been on my own (working as staff as an SRNA) for about 2 months now. Overall, things have been going well. I've been doing mostly bread and butter cases, but, for the most part, I've been happy with the decisions I've made in the OR.

But, as the saying goes, you are only as good as your last anesthetic. So, last week I'm assigned to do a robotic myomectomy. The supervising MDA is a super nice guy, but also very hands-off. I'm not sure if this is because he trusts me or just doesn't care (?both). He always tell me "do whatever you want" or "see how it goes" when I try to ask specifics about a procedure. I feel like I could be running halothane and he wouldn't say anything.

So, patient is 33y, healthy, 75kger. Scrub tech pulls me aside as I'm setting up and tells me that the surgeon is "really good" and that we will probably be done in an hour.

Patient in the room: easy intubation. 2nd IV in, arms tucked, everything looks good. I gave 100mcg of fent with induction. After much setup, the robot is docked and we are ready to go. Surgeon is letting the fellow run the robot.

20 minutes is surgeon notes that the patient is "a little oozy." No major bleeding, but he tells no toradol for this patient. I was thinking about more narcotic anyways (patient HR has been creeping up since insufllation) so I decide to give 0.8mg of hydromorphone. 1 Hr later, I give another 0.4 with 50mcg of fent. 2hrs later I give another 0.4 (3.5hrs into surgery). Surgery ends up taking 5 hrs.

Robot is undocked, trocars out. I turn on 50% N2O at high flows, and slip her 20mg of propofol, but I'm a little slow turning the sevo off. The surgeons close the rest of fascia fast. She has 4 twichtes, I give the reversal.

Skin is closed. N2O off, I have .3-.4 end tidal sevo. I'm hyperventilating the patient by hand to get it off. MDA into the room for wake up.

End tidal sevo is now reading 0.2%. I stop hand ventilating her. It takes a good couple minutes for her to start breathing (not surprising since I had been hyperventilating her). She's pulling decent tidal volumes (200-300ml), but her breathing pattern is irregular. Pupils are divergent.

End tidal is reading zero %. 3 to 4 minutes later, the patient is show no signs of waking up. No response to suctioning, jaw thrust, nothing. MDA is pissed. He asks about the narcotic, when I tell him he rolls his eyes "are you kidding me." OR nurse moans loudly. Scrub tech looks disgusted.

I give her a big hand breath. End tidal shows 0.4% MDA is on the phone with the PACU - "set up a vent, call me when it's ready." I'm just glad he isn't having me give narcan. I put the patient back on the vent at a high MV.

Evil eyes from everyone in the OR. We are coming up on close to 10 minutes. Suddenly the patient bucks and opens her eyes. I put her spont vent. Great volumes. Tube out.

The PACU nurse makes me repeat three times that I gave the patient 1.6mg of hydromorphone. As I finish report, the surgeon comes up and starts taking the patient about the surgery. The patient is obviously in no state to remember anything he is saying. He looks at me like "WTF she is supposed to go home in 2hrs."

I felt awful about the wakeup and now I have all weekend to think about it.