So I graduate in December and feel like I might actually make it. I am finishing up a heart rotation and love it and feel like it has increased my confidence quite a bit. So, today there are no hearts and I sign up for a knee replacement and a hip fracture. The patient with the hip fracture is 59 years-old , 68 kg, history of hypertension, (2 anti-hypertensives) recurrent Afib (on coumadin) and , ex-smoker (quit 10 years ago), and no other significant history. The INR is 1.6 and she gets 2 units of FFP and no spinal. I intubate her on her bed we then move her to the table and put her in right lateral position. She has her twitches back from the Anectine and I give 10mg of rocuronium. PIP is near 50 but lungs sound clear maybe a little diminished check, no kinks in tubing,check her twitches within 5 minutes still 4 twitches with fade so I give her 10 mg more of rocuronium. Okay, so this is where I swallow my pride and realize I have so much more to learn and admit it for the world to see.

I honestly froze up and was grasping for ideas of what to do next. I tried to switch to pressure control but ventilation was inadequate and I switched her back. My preceptor is in the room and he suggest suctioning which we did with no secretions. Saturation still 95-97% with adequate VT but PIP still ~50 with good lung compliance when hand ventilating.. The ETCo2 is around 40 and little more than a MAC of sevo. He suggest we pull the tube back some which I didn't consider because I had good breath sound in upper lobes so I didn't think tube was too deep. Anyway, that didn't change anything. The MDA comes in and decides to change I:E to 1-1.5 which just didn't click in my head at the time and I'm still wondering what that would do in regard to PIP especially if she had obstructive issues it would seem to make co2 and PIP worse d/t less expiratory time?? Anyway, nothing immediately changes and he suggest Ephedrine to try and get some beta 2 activation and we give 10 mg, this goes on for 10 minutes or so and saturation never drops below 95% and I put her back on pressure support and she smooths out yet PIP never drops below 36-37. Lots more to say about the case as I ended up having some hypotension issues, 500ml blood loss, desaturation during vent weaning, etc, etc.

I finally was able to extubate her and breathing and saturation was actually better. My whole point is "I can give a hell of an anesthetic" when things go as planned but when they don't I have a LOT to learn. I can think of many of these interventions sitting in the classroom but doing it instinctively in the OR is just not there yet. I walk away from today realizing even more that there is no 'easy" case. I won't even tell you about the knee other than to say patients with spinals should not grimace and moan when incision is made...