What does it mean to be called in? Part 9-Waking up.

The call case is nearly complete. The surgeon has dropped, which means he has finished and probably left the room to put post-op orders in and speak to the wife.

The two most dangerous times in any case, from an anesthesia standpoint, is going to sleep and waking up.

There can be shifts in blood pressure at both occasions. The heart rate can be affected. The respiratory effort has to be engaged as the patient has to breathe on their own after surgery. All of the gas that has been maintaining the general anesthesia is turned off and the patient breaths off the gas, either by the machine, or on their own.

Different CRNAs will turn off the gas and begin the waking up procedure at different times. It all depends on what they are comfortable with. Many times the waking up process starts too soon and the patient starts to emerge from anesthesia at the wrong time. This is usually before the surgeon is finished closing and the surgeon will tell the CRNA that the patient is bucking. Or coughing against the tube. And the CRNA will need to add more medication (likely a paralytic) to the line or reestablish gas to get the patient deep enough to finish closing. This is fraught with peril if the case in question is a hernia, because the entire repair can be ruined with ill-timed coughing and must be redone.

Sometimes the case is quicker than anticipated by the CRNA and medication reversal must be given. There are several medications that can do this. And they all have an associated cost. The other option is to wait for the medication and gas to wear off naturally. This is frowned upon because it can take many minutes and there is always another case to get started. Also, OR time is charged by the 15 minute increment and it costs the patient money to have a slow emergence from anesthesia. It also exposes the patient to the risks of emergence.

The scrub tech puts the dermabond, or skin glue on the skin over the port sites. This is the dressing that the patient will go home with.

During this time, I keep an eye and an ear on the CRNA and the patient as I am doing my end of case work. I catch up on the charting of the times, except for out of room time. I bring in the gurney and untuck the arm, if that is the arm that is closest to the corridor door. I put the gurney next to the bed, adjusting the height as needed, put the slide board on it with a chux pad. I lock the gurney. After I have done this, I stand by the side of the gurney and am ready to assist the CRNA as needed. I have my OR phone in my pocket in case I need to call the anesthesiologist stat. I watch the patient and the CRNA closely, watching the color change of the face, and the monitor numbers. The scrub tech is breaking down her table and stacking instruments.

The CRNA is making final adjustments, checking pupillary position, checking patient’s response. Some will wait until the patient grimaces or opens their eyes to command. The patient will no remember any of this but this is a way to determine readiness for extubation.

Finally the CRNA is satisfied and, suctioning the mouth, deflates the balloon on the endotracheal tube and pulls it out. The entire reason I did not pursue CRNA work is that there is a year in ICU that is mandatory. I have no desire to work in the ICU and I hate respiratory secretions. That is a hard no for me and my nursing kryptonite.

Assessing for responsiveness the CRNA will put a nasal cannula on the patient. And a mask over it. Intubation and emergence are aerosol producing events and if covid has taught us nothing it is to control coughing. Extubation does not always lead to coughing but it most likely does.

If the PACU nurse or anesthesiologist is about I will ask them to grab feet and assisting with transfer back to the gurney. If the patient is over a specific BMI I will insist on this. Otherwise a pillow is placed under the patient’s calves. Or, better yet, a pad from the armboard is, slick side down. It slides better.

The CRNA controls the head and counts us in. The scrub tech log rolls the patient to their side. I always am the puller and I place the chux and slide board under the patient. We allow the patient to roll back to their back and glance at each other. I do a quick check of the locks on the gurney, by tugging on it, and I say to the group “Locked.” The CRNA counts us 1-2-3 and I pull the chux pad on the slider, the scrub tech pushes from the opposite side, and the CRNA brings along the head and shoulders. Presto, the patient is on the center of the gurney and the legs slid over on the upside down armboard pad. When I am the puller the slide board is visible on the other side of the patient, ready to be grabbed my the scrub tech. Sometimes we have to roll the patient a little to get the board out, depending on their size and the skill of the puller. I take the upside armboard pad out from beneath their calves and replace it on the armboard.

Why am I always the puller? I have a body mechanics routine for this. I do not use my back. Never. I have seen many nurses and techs get injured being the puller. I use my glutes and my hamstrings. When I was a CNA in a nursing home I assisted a 400+ patient out of bed every morning by honing this technique. I’ve tried to teach it to others but they prefer to rely on their back muscles, despite repeated warnings not to. Sigh, you can lead a horse to water…

Now that the patient is safely on the gurney, the CRNA assesses their breathing again. I pull up the side rail on the side I am on and grab the chart and the specimen bag, tucking it on the end of the bed. Using the OR phone I call PACU and tell them we are incoming.

The CRNA nods and connects the nasal cannula and to the bottle of O2 that is on the gurney. I unlock the bed and pull it away the OR table. Pulling up the other siderails, we get ready to move out.

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