I slept very well having taken a Sonata (Zaleplon) and wearing sleep comfy headphones. Sonata is a very short-acting sleeping pill that keeps me from waking up a lot during the night but has no sedation after 6 hours. I had first used it for my 11-hour flight to Fiji as I knew that I would have to work on the day of arrival and wanted to guarantee some good sleep on the plane. At breakfast, some first-time mission people said they slept poorly as so nervous about the first day of work. I wasn’t very concerned as I knew that even though my first patient was a 6-year-old (and I haven’t done a pediatric case in several years) a 6-year-old’s anesthesia is not that different from an adult’s. For a 6-month-old I would have switched rooms even though I was working with a CRNA for the case. And other than supervising the CRNA in the eye surgery room (with the rest of the schedule being just adults for cataract extractions) I was only supposed to give breaks to and do nerve blocks for the ACL reconstructions for the anesthesiologist, Marcia, who was in the room with 2 knee arthroscopies and 2 ACLs.
Every morning after a quick shower I went to the outdoor kitchen area and had coffee and a Clif bar for breakfast. It worked out great that my two roommates were surgical techs because we all needed to be at the hospital by 6:15am so we always all woke up around 5:30. Some women mentioned the daily inconvenience of some of the roommates being surgical team members (getting up early and using blow dryers, etc.) while the others were primary care team that didn’t need to get to the clinic until 8am to start seeing patients.
The 15-minute walk to work along the path through the woods was very peaceful. Listening to the birds and the babbling water over rocks in the streams provided the short period of mindfulness that is supposed to be so good for starting the day but is so rarely possible in our hectic lives.
Right after entering the building I saw the first patient and his mom in the post-op area where they were giving him his own space to get ready rather than with the other patients in the busy pre-op area. He and his mom spoke no English so I introduced myself and tried to connect with him a little but he looked very scared. He had his other eye surgery 6 weeks ago, which went well, but maybe he didn’t enjoy the experience much. As soon as I changed clothes I checked that Allia (CRNA) had all she needed in the room and then went in search of some liquid Tylenol to put 0.75mg/kg of versed in to pre-sedate the boy. In about 20 minutes he went from scared/shy to smiling/giggling. Allia carried him to the OR and the RN helped us get his monitors on and then we did a mask induction (a little slower than in the US since we had no nitrous oxide) with Sevoflurane. All patients also got 100% oxygen since we had no medical Air supply. Once he was well anesthetized (limbs floppy) I placed an IV and Allia placed an LMA and then the surgery started.
It was confusing at first because until the morning of surgery, I didn’t realize the eye surgeon (and a fellow) were Hondurans who usually worked in the city but came to the clinic to do charity cases. As we had not gotten a list of people on the mission and their roles. They also had a nurse with them who dealt with all the eye equipment. And since they spoke Spanish to each other during the surgery (although the surgeon was fluent in English), the anesthesia team, scrub tech, and circulating nurse had no idea how the surgery was going. While I was with the patient before surgery, I introduced myself to the fellow (thinking he was the attending surgeon) and then the actual surgeon when they arrived. I was interested in the case since juvenile cataracts are rare in the US and I tried to get some information from the surgeon about how severe the blindness was, for how long, and what had caused it but he just gave a vague “who knows?” and wandered off. I noticed later when reviewing the adult cataract patients’ charts that many were here for their second eyes and had their previous surgeries done with a local CRNA providing anesthesia under ?supervision? of the eye surgeon. That was fine since it is arguable that an anesthetist even needs to be present at all for modern cataract surgery using topical anesthesia drops (in much of the world an RN just gives a bit of sedation or none at all). I wondered though, why we were staffing a surgical tech, circulating nurse, and anesthesia for the cases when they had their experienced techs and nurses who usually did the cataract cases and there was a Honduran CRNA there acting as a translator in the clinic. Wednesday there would also be a full schedule of cataract cases in one of the three ORs.
During the case, I went and saw the next cataract patient in the pre-op area. There was always a translator available in the pre-op area to help with interviews by surgeons and anesthesia and consent. I could usually do 75% of the interview and exam on my own but always had the translator help with any details I couldn’t manage and ask at the end if the patient had any more questions. The patient woke up smoothly (again a little slowly as no nitrous oxide) and we took him to the recovery room. While Allia gave a report to the nurse I went back to pre-op to see the 3rd patient since I assumed the adult cases would move more quickly. While I was talking to the patient the OR coordinator JC came in and asked if I was doing anesthesia for the next eye case. I said yes but wasn’t clear on why he wanted me to come to the room as the CRNA was going to be in there for the case. It turned out that the eye surgeon or his fellow had brought the patient back to the operating room himself without our circulator RN or the CRNA meeting the patient or checking the paperwork. I scrambled to connect the patient to the monitors before they started. I guess this is the usual practice when they do cataracts (with local Spanish speaking staff) but it was not acceptable for us. It just further made me wonder why we were involved in these cataract cases. I spoke to JC and he spoke to the surgeon and they waited for our circulator and CRNA to see and bring the patients to the OR thereafter.
I didn’t think the remaining 8 adult cataract cases would take that long but the surgeon was teaching the fellow and they did retrobulbar blocks on several cases that they thought would be more difficult. The whole eye OR team also took a break between cases for both breakfast and lunch.
There was a big full breakfast every day for us (served by our general volunteers). I always just took a small bowl of fruit and coffee as I usually don’t eat anything more than a Clif bar before lunch.
With the eye room moving along well I did the pre-operative evaluation and consented the first ACL patient for an adductor canal nerve block which I had been told was what the surgeon in room 3 liked for his patients. Marcia who was the anesthesiologist in room 3 had told me on Sunday that she “needed to be” in that room because she came to give anesthesia for Dr. “Sig”‘s patients. This confused me as the surgeon assigned to room 3 was Dr. Redler but I was fine with it and happy to do the blocks to speed room turnovers. She had said she preferred to be in a room by herself as there hadn’t been CRNAs on any of her previous missions. I was surprised that we had 2 CRNAs and 3 MD Anesthesiologists for just 3 Operating Rooms. I could understand 4 in case someone got sick or injured but 5 seemed excessive. We ended up with having one MD in a room by themselves (Marcia day one and then me the other 4 days) and 2 MDs each supervising just one CRNA. Theresa (the other MD anesthesiologist) had brought a CRNA with her from CT so they worked together each day.
All good until …. Theresa whispered to me in PACU where I was getting the ACL patient set for their block that…. “it’s nothing personal…but Dr. Redler would prefer if I did the blocks on his patients since we work together back home”. Of course, I took it personally as I am sensitive that way.
But mostly I was just confused as Marcia was in room 3 to “work with her home surgeon” but Dr. Redler was the scheduled surgeon in room 3 and now Theresa was saying she was his home anesthesiologist. It would take me another day or 2 to figure out that there was another surgeon (Scott Sigman) on the mission who had no OR cases scheduled but just participated in other docs cases, he was from Lowell mass and had brought a large group of people from there. It was only his second One World Surgery mission but he was friends with Dr. Redler.
Room 2 had some arm cases and once the last case was in the room Theresa took over supervising the last cataract case and I was told I could go. I was a little mopey as I trudged back to the Moscati Center. I just wondered why I had traveled from Buffalo, taken a week off work, paid for my flight and the $1000 donation just to supervise a single CRNA. I didn’t feel like I was needed. I knew that a run would perk me up so I got changed and headed out the gate and up the dirt road (after slathering myself with sunscreen and DEET, it was sunny and 80 and humid). Only a few hundred yards ahead I noticed was Stephen who I had run with on Sunday. I sprinted for a few minutes and then snuck up to him and grabbed his shoulder and yelled “roar!”. He was very surprised but he was the kind of person who appreciated it. We ran together but I listened to my book on tape and he to music except for some brief comments.
When we were done I found Panther lying outside the gate (he wasn’t allowed in the Moscati center, moocher) and sat next to him and got some serotonin therapy by petting him. Unlike Fifa, he didn’t want to lick off my run sweat. I felt better mentally and physically.
My “no carne” meal was a little bland so I was very happy it was someone’s birthday and we got dessert!
Theresa had changed the OR assignments as Marcia now wanted to not be in an OR but wanted to be out so that Theresa could teach her some nerve blocks she didn’t know. Theresa did a ton of nerve blocks in Stamford and taught courses on them. I told them I was happy to be in a room by myself but would like when possible to do my nerve blocks.
I was excited to work with Dr. Antunez who had grown up as an orphan at NPH and was now medical director of the hospital and an orthopedic surgeon.