Life and death decisions in the emergency room, anesthesiology is the focus

Many years ago, in a hospital.

As night fell, the lights in the emergency room were on. There were no piercing alarms, no hasty rescue noises, and a bunch of people were working on a plan.

What was different from the past was that in addition to the emergency doctors, orthopedic surgeons, anesthesiologists, and even the patients' family members seemed to be present.

There are three core issues discussed:

1. Do you need surgery?

2. What kind of surgery should be performed?

3. Do you want to have surgery immediately?

The reason why we discuss these issues is that this patient is very special: advanced age, hip fracture and arm fracture, unconsciousness, many years of history of hypertension, cerebral infarction, pneumonia, etc., make the orthopedic surgeon dare not decide on the surgical plan easily.

The orthopedic surgeon's skills were second to none in the local area. However, the patient's condition was too complicated, so he had to worry about the patient's safety and recovery after the operation.

Such a complicated patient, if he is not treated properly, it will ruin his reputation for the rest of his life, he thought to himself.

It had been several hours since the accident, and the open fracture of the arm needed surgery as soon as possible. However, once the surgery was done, what would happen to the hip fracture? In addition, would there be any danger during the surgery?

As an anesthesiologist, if it is for safety reasons, you can actively suggest just breaking the arm. After all, this operation only requires upper brachial plexus anesthesia. It is almost equivalent to local anesthesia, plus with ultrasound guidance, there will be almost no major problems, and the effect can be guaranteed.

However, he was struggling internally when he thought about the impact of delaying the surgery on the patient after the operation.

Related studies have shown that early surgical treatment can not only relieve patients' pain, but also reduce the incidence and mortality of postoperative complications and improve postoperative self-care ability.

Compared with surgery within 48 hours of admission, the 30-day all-cause mortality rate increased by 41% and the 1-year all-cause mortality rate increased by 32% in patients who underwent surgery after 48 hours. The longer the surgery was delayed, the higher the in-hospital mortality rate. Surgery within 48 hours could reduce the risk of postoperative death.

In addition, missing the optimal time for surgery will also lead to a significantly increased risk of complications such as lung infection or deep vein thrombosis.

However, once you take on this job, you won't have a rest that night. It's not just a simple "fight until dawn", but a night of exhaustion.

Despite this, the anesthesiologist, who has been working to ensure the safety of patients' lives for many years, quickly put this idea aside. Looking at the old man in front of him who is about the same age as his father, he cannot be selfish and must save him!

To win this battle, preoperative evaluation is necessary. It can be said that the level of evaluation determines the outcome of this rescue.

Soon, the anesthesiologist completed the assessment of heart rate, respiration, blood pressure, temperature, pain, mental state, medical comorbidities and treatment status, pre-injury mobility and function, pressure ulcer risk, nutritional status, water and electrolyte balance, etc.

Combined with imaging studies (X-rays, CT or MRI scans), he already has a clear idea of ​​what may happen during the operation and what may happen afterward.

In order to minimize the impact of anesthesia on the patient, the anesthesiologist used a combination of spinal anesthesia and fascia iliaca block.

Procedure: Before positioning the patient, perform iliac fascia block with local anesthetic on the affected side. Light-weight unilateral spinal anesthesia (the affected side is upward), 0.2% low-dose light-weight bupivacaine solution 7.5mg, push injection for 30s, and maintain the affected side upward position for 15min.

At the same time, another orthopedic team was preparing to perform surgery on a broken arm. Everyone wanted to save the old man from having to go through the surgery twice, thanks to the positive attitude of the family members in the emergency room. The attitude of the family members is the key to the doctors' courage to fight.

At first, orthopedic surgeons were worried about whether local anesthetic poisoning would occur. After all, they also often use local anesthetics. However, the confident attitude of the anesthesiology department and the arrangement of staggered drug peak hours once again made them feel that anesthesia was a reliable comrade.

In fact, it is also thanks to the development of ultrasound guidance technology in recent years. Otherwise, anesthesiologists would not dare to take this job easily. For complex diseases, any problem may turn into a big problem.

Finally, with everyone's concerted efforts, the old man recovered and was discharged from the hospital a few days later. Although the old man may not know that every opinion of the doctors involved in the discussion at that time may determine his life or death, everyone felt that this was normal.

Especially in the Department of Anesthesiology, the torment, anxiety and pressure of waiting for him to give his opinion under the spotlight had long passed.

Liu Gang, Binzhou Central Hospital

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