April 1, 2013
Volume 77, Number 3
Observations: An Anesthesiologist in the E.R.
N. Martin Giesecke, M.D. Editor, ASA NEWSLETTER
My first trip to the emergency room was in August 1969. My 10th birthday was quickly approaching and school was going to start in about two weeks. The E.R. I visited was at Parkland Memorial Hospital, where my dad, A.H. “Buddy” Giesecke, Jr., M.D., worked. Not quite six years earlier, President John F. Kennedy had been taken there – but that’s another story.
I had suffered a fracture of my right tibia and fibula in a bicycle accident, and my dad took me there to have a cast placed. The only thing I recall about that visit was seeing a gentlemen lying on a stretcher in the hallway. He had a sheet pulled up to his chest and that portion of the sheet over his abdomen was stained with blood. The man saw my dad and me and asked us for some water. Of course, my dad, understanding the risk of oral intake and a probably urgent exploratory laparotomy, told the man he could not have any water. The man looked at me and said, “I’m so thirsty.” I did not know about recent intake and induction of anesthesia. Maybe back then I would not even have understood the concept. But I do remember thinking that we should give the man some water – he looked and acted so thirsty.
The next time I stepped into an emergency room was as a medical student at UTMB in Galveston. It was an interesting, busy place. Of course, it amazed me that back then, whenever an airway needed to be secured, the anesthesiology resident was called to handle the job. It was also intriguing
that the anesthesiology interns who were on the E.R. service were the ones placing central vein access and running codes. Maybe that was just my medical school, but it showed me one aspect of near first-line trauma therapy provided by anesthesiologists.
I returned to the emergency room as an intern. Now I was the one placing lines and running the codes. I remember a couple of scenarios quite well. One was a well-known local binge drinker who provided easy intubation practice for the city’s EMTs. This man would drink himself into unconsciousness and become intubated by the EMTs. Obviously, this was to protect his airway from aspiration. The patient would reach the E.R. and be placed on a ventilator. About five hours later, he would wake up, self-extubate and leave. This happened a number of times and was the reason the patient was well known to the EMTs and to the E.R. We cared for quite a few patients who were in police custody (or incarcerated). One of these patients was causing quite a ruckus, shouting profanity at everyone and grabbing the nurses who were trying to care for him. I don’t recall his reason for admission, but I do recall that after a quiet talking to by the anesthesiology resident, who just happened to be in the E.R. at the time, the man began toeing the line. I asked the resident what he had told the patient. He said, “I showed him this syringe of succinylcholine. I told him what it did. I said that if he did not start acting in a respectful manner, I would inject the med in his I.V. and let him think about his ways.” This latter escapade was not a highlight in the anesthesia care of the trauma patient, but it did leave an indelible impression on an intern’s brain.
After my time in the E.R., I was able to sign up to be a flight physician. We would accompany a helicopter pilot and a trauma nurse on emergency runs and patient transfers. There were some harrowing stories from other flight doctors, typically revolving around extraction of trauma victims from crushed automobiles. I finally was able to go on one of those calls. We flew to a fishing dock where the shrimp boats were tied parallel to each other. The nurse and I climbed onto and over two shrimp boats before we reached the boat where our patient laid waiting. Local EMTs assisted us as we loaded the conscious man on our stretcher and took him back across the boats to the waiting helicopter. The fact that he was conscious and coherent was a mystery to me, as one side of his skull obviously had a depressed fracture. A large, bloody monkey wrench lay near where we found the patient.
But most of the flights were more mundane transfers of patients from outlying, small-town emergency rooms to our tertiary care facility. One of my anesthesiology resident colleagues was also a flight physician. As many of us witnessed, he realized that once airborne, the helicopter was too noisy for us to auscultate Korotkoff sounds while attempting to measure a blood pressure. Furthermore, vibrations of the aircraft made it difficult to palpate a returning pulse once a blood pressure cuff was deflated. Both of these issues made it problematic to appropriately measure the blood pressure of patients while en route. This resident began using a relatively new technology, pulse oximetry, to measure systolic blood pressure. When inflated, the BP cuff would stop the SpO2 waveform. Once systolic pressure was restored, the saturation waveform would return. This innovative thinking was another example of the care an anesthesiologist provided to emergency patients.
I have visited emergency rooms at least two more times as a patient since my broken leg. Nevertheless, most of my visits to the E.R. remain those for obtaining or protecting an airway, or providing vascular access in patients in need. However, anesthesiologists do far more for the care of emergency patients in general, and the trauma victim specifically. Read on to learn some of these stories from other anesthesiologists around the continent.