Tag Archives: Anaesthesia

Humour and Humanity

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I have seen a lot of SBL and Magmatic Magne this week: a lot of time in theatre, though I also endured some sessions with Mr Ikea, trying to follow the instructions for putting together a small and inoffensive chest of drawers. The thing had been undergoing assembly over several weeks now and the already-completed drawers had been huddling on a table in the corner, minding their own business except for the odd occasion when it was necessary to squeeze past them to get to the dog food. As is the tradition with Ikea furniture, a small error had been made at a crucial point about half-way through, thereafter it followed that everything else was just far enough out of place that the finished product wouldn’t go together. Dagny, active in this, as in all things was the perpetrator of this tiny error, and Magne had seized upon the opportunity to remind her of this fact, every time anyone went near. Still finally the thing was done, and all the drawers were in place. My first achievement of the week.

About an hour later, I found myself managing the anaesthetic for a mammary tumour operation. Dagny asked me to get theatre ready, and when she asked “Are we all set,” I replied (with the honesty and diligent self-confidence I try to maintain at all times) “I hope so.” In fact I wasn’t. I had failed to check if she wanted to use gaseous anaesthesia (a lot of the operations are carried out with a combination of deep sedation, local anaesthesia and propofol infusion) so she went and switched the machine on herself. A few minutes later, with the dog prepped and installed, I noticed the ominous stillness of the patient’s chest. She wasn’t breathing. The usual sense of consternation kicked in. Just work through it logically, I told myself, trying to remain calm. I checked the dog’s colour. It was pale, but it had been pale before we began. That meant that it was even more urgent though to discover what was wrong. I checked the level of anaesthesia. The eye was rotated down. Fine. I grabbed a stethoscope and listened for the heart because the heart-rate monitor wasn’t detecting anything. The heart was racing, as at this point was my own. It was at that point that Dagny quite casually pointed out that the rebreathing bag had filled up completely because the pressure valve hadn’t been reopened after testing. She hadn’t been aware that the dog was not breathing, and in her calm assessment, had just noticed what I was failing to pick up. Panic is a terrible thing. I can recall a time in the emergency clinic when whatever life threw at me, I knew I could handle it but five years off has sent me tumbling back into “starting out” mode.

Dagny talked a bit about her life during the operation. She told me that she was only six years old when she decided that she wanted to be a vet. Despite discouragement from those around her, who thought that as a woman she should do something less ambitious, more feminine, she planned out her life with ruthless efficiency and finally achieved her aim. No wonder then that with such determination to succeed, she ultimately went on to become a partner in the very first dedicated small-animal clinic in Norway.

By Thursday, I started to feel everything was more under control. I assisted Magne with a cherry-eye operation. It’s amazing to see him putting in the tiny sutures, ensuring that nothing is left to irritate the eye. Just before lunch a dog came in which was in respiratory distress. To my amazement my self-confidence suddenly kicked in and I was easily able to help out and even offer guidance. At one point, I suggested the possibility of draining the chest and Magne and Irene looked at me as if I had suddenly sprouted green bushy eyebrows. How odd it seemed, and yet it brought it home to me that despite the irony of the situation, I am much better with a frank emergency than with anything routine, and perhaps that shouldn’t be surprising given my history of working in an emergency and critical care setting for the last few years of my career in Scotland.

Later I found myself back in theatre once more, as Dagny and Magne, without even the benefit of Ikea instructions, set out to fix a fractured humerus in a young dog. After the lunchtime emergency, I managed to impress Magne once more with my astonishing ability to intubate a dog without a laparoscope. This has never seemed like any great achievement for me. I started out, all those years ago, in a small animal practice where everything was on gas, and everything was intubated and I don’t think I ever even saw a laparoscope. As with everything else, a good nurse and the correct positioning is essential, so thanks to Irene for that. When Magne returned from the hunt for the missing laporoscope, he found to his amazement that the dog was already in theatre, fully hooked up to the machine and almost ready to go.

“You know,” he said to me as he walked to the table, “you’re really quite useful to have around. I think you should work more hours!”
I felt rather diffident about this. I actually like just working two days a week and keeping my options open for overtime. “Well maybe I could come in and work Fridays as well,” I offered.
He just shook his head. “That would be no good at all,” he said with a twinkle in his eye. “I don’t work Fridays,” and with that, he turned away and started to cut.

Smil

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Beike came in last week to have his teeth cleaned. For those who aren’t aware, Beike is my friend Marian’s dog, a handsome Border Collie with a passionate love of balls and Frisbees. That’s him at the top of the page. Beike, Marian and I often go walking together and so I know him well. I think most vets would agree it’s more difficult treating an animal that has become a friend, whether it is an acquaintance from outside work or a long-standing patient that you have got to know over time. Anyway, I was nervous before he arrived and there was no escape because Marian had specifically requested that I treat him.

He went to sleep very quickly and we soon had him through in the dental room. The dental room is one of my favourite parts of the clinic. I’ve never worked in a practice with a dedicated dentistry area, but it undoubtedly makes for better treatment, both for the vets and for the animals. There is suction ventilation to remove the spray from the ultrasound descaler, excellent lighting that can be manoeuvred into position so you can see right into the mouth, polisher and drill, as well as more dental instruments for removing teeth than I have seen anywhere else. There’s even a specialised x-ray machine.

Anyway, back to Beike. The only complication was that he had a broken tooth right at the front of his mouth. In fact, if you look at the picture at the top of the page, you can see it. Happily for me Wivek was available to help. As well as wonderful facilities, Tu clinic has the best veterinary dentist I’ve ever come across. The more I get to know Wivek, the more impressed I am. She seemed very quiet to begin with, she never shows off, and yet she knows an incredible amount. If I read up about anything I can talk to her, and she is still ahead of me. Anyway when it comes to removing teeth she is second to none. I began to loosen Beike’s tooth, but as usual I came to a (literally) crunching halt. Wivek came to the rescue and very patiently worked away until, as if by magic, she produced the intact root. I, of course, was watching carefully. It’s great to learn new things!

After Beike’s teeth, it was nearly time for lunch. Every Thursday lunch is laid on and we have a practice meeting so that SBL can tell us all that we’ve been doing right and wrong. This week it was car parking. Apparently we are supposed to park down the side of the building, leaving the spaces in front for the clients. I kept my head well down at this point of the meeting because since arriving I have invariably parked my car in one of the prime sites. I have always stayed away from the doorways. I had worked out that when people had to take their sleepy animals to the car, it was better they could park there. But other than that, I have shamelessly avoided that difficult, overcrowded corner where all the staff seemed to leave their vehicles. Not any more it seems.

The meeting always ends with the Ukens Smil (The Week’s Smile). This is when the staff get to thank each other for favours done and congratulate one another for their achievements. There’s a little box in the staff-room with a hole in the top, and when someone does something nice, you write your thanks on a piece of paper and slip it into the box. Every Thursday the compliments are read out for everyone to hear. The person who gets the most smiles gets a packet of chocolates, conveniently named “Smil”. Incidentally, Marvellous Magne, whose English is good, but not as good as the vets who studied in English has never read my blog and therefore was wholly unaware of the extent of my evilness. He finally discovered last week that I had given Dagny the nickname, Scary Boss Lady. Since then he seems to have been Smil-ing rather a lot!

And finally, as promised two weeks ago, I attach below photographic evidence of the chicken-head ritual. There has been speculation that these events are part of contemporary Norwegian culture, similar to their habit of filling highly flammable wooden houses with candles each Christmas, or the more localised Jaeren farming custom of blasting liquefied animal dung into the air whenever washing is hung out to dry. However my personal theory is that this particular activity is related to Norse mythology, more specifically to Thaw, Goddess of Deep-Chilled Poultry. Irene has now gone on holiday and is sunning herself in Thailand amongst the mosquitos. If only it had been Turkey….

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Metzenbaum Meltdown

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It’s been a week of instrument incidents this week, at least on Tuesday anyway. I didn’t sleep well on Monday night, and by nine o’clock on Tuesday morning, I confess I was wafting round the practice, trying to be all efficient. It wasn’t easy. Somehow the standard tasks of ensuring the rooms were well stocked with needles and syringes seemed unusually complicated. I thought I was finally getting into my stride though, as I emptied the instruments from the autoclave, put them away, and packed up a raft of new kits for sterilisation.

Irene came into the room at this point and started to chat. My brain being otherwise occupied (the routine tasks were taking up all of the limited space in my one cylinder brain) I looked at her vaguely and failed to answer to her satisfaction. She looked at me with narrowed eyes and her head on one side.

‘Are you tired this morning? You’re not usually this quiet. I went to a concert last night. I’m tired.’

I admitted that I wasn’t at my best. My inclination was to remain silent, but it seemed impolite. ‘What concert did you go to?’ I had to try to appear normal at least. She named a singer I had never heard of and I tried to carry on the discussion as I set up the autoclave to sterilise the instruments I had just packed.

The autoclave has something of a pre-set routine. When you first switch it on, it automatically says that the door is open, and the locking mechanism doesn’t work until the programs become available. So I meticulously emptied the outflow, ensured the distilled water was topped up and then, to pre-empt the frustrating period when the door won’t lock, I carefully pushed the door to and set the locking mechanism in place. With a sigh of relief that everything was beginning to settle down, I turned my back as the machine began to run through its program. Irene had continued chatting, but now she was looking at me with a very confused look in her eyes.

‘So what’s in the autoclave?’ she asked. I frowned at her for asking such a crazy question. Obviously the packs I had just set up so carefully, but her eyes weren’t looking at me. They were directed towards the neatly stacked rack with the kits all neatly packaged in their white paper parcels. I had just set the autoclave off on its hour long programme with nothing inside.

All day long, I seemed to be all fingers and thumbs. There had been a spell lately when it seemed I was unable to do the simplest task without dropping something on the floor, and on Tuesday the effect was magnified. Opening up some suture material while Dagny was operating, I thought that rather than risk handing it directly to her from the package, I would drop it on the instrument table. Of course, it flipped out of my hands and missed by several inches. Somehow, every needle I used became detached from the syringe. I spent so much time running in and out of theatre to get new ones that I began to worry that someone would comment. It was a relief therefore when Dagny, usually so efficient, managed to drop the straight scissors from her kit. I retrieved them and offered to get a new pair.

‘I’ll need some Metzenbaums anyway,’ she said ‘you can just get some of those and I can used the curved scissors for everything else.’ Metzenbaum scissors are long slim scissors designed to cut delicate tissue. I collected a pair from the instrument cupboard. Once again, Dagny being occupied with her operation, I decided to drop them directly onto the instrument table. I should have known better. They too slipped to the floor with a clatter that seemed so loud in the quiet operating room. Fortunately, Dagny was not in Scary mood (in fact, she has been so unscary lately, that if I didn’t know how much she loved her nickname, I might feel the need to change it) and she just laughed and asked if we had another pair. At this point, Magne, ever the gentleman obviously felt that he should join in with this game of throwing things on the floor and dropped the chuck-key of the drill. Really I didn’t feel so bad then. The final flourish occurred as Dagny was stitching up. As she went to set the scissors back on the table after cutting her suture material, she misjudged it and the last pair went toppling to the ground. She completed clipping the line of sutures using a scalpel blade. Obviously the idea of asking for yet another pair seemed too high a risk. After all, judging by earlier events, I probably would have stabbed her in the toe.

Thursday, thank goodness, was much more relaxed. Dagny’s sister-in-law brought in her lovely little dog (that’s him in the picture at the top of the page) to be castrated. In contrast to Tuesday, theatre was a hive of extreme efficiency. I’ve never seem Dagny operate so swiftly. So much so that I barely had time to stabilise the anaesthesia before it was time to switch the machine off. I spent the rest of the morning discussing some modification of the anaesthetic regimes with Wivek, who is thoroughly knowledgeable in this, as with so many other things. We want to be sure that the patients are as comfortable and as safe as possible during surgery, and so we are reviewing the analgesic (pain-relief) protocols. When all is said and done, however many times you throw your scissors on the floor, in a good veterinary practice the well-being of the animals always comes first.

Holiday

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Even after many years, I still greet Christmas and the New Year with a heightened sense of joy that I don’t have to work on either day. All round the world, many wonderful people in the emergency services give up those days to help others, and I send my good wishes to all my friends and colleagues who have been, and will be working over the holiday period this year. I expect when I return tomorrow, there may be a few Christmas related cases. It only takes a moment or two for a dog to eat something that he or she shouldn’t, and chocolate and raisins can be toxic for dogs, as well as the simple problem of too much turkey.

Last Tuesday, the day began as I walked through the prep-room on the way to change into my uniform.  Linus, (whose picture you can see at the top of the page) had been very ill and vomiting for a few days, and he was in a lot of pain and seemed utterly exhausted. His abdomen was so painful that Dagny had to sedate him to examine him properly, and when she did, she could feel something. Whatever it was, it wasn’t visible on the x-ray (some items show up clearly, but not all do) so the only way to help Linus was an exploratory operation. His owners were naturally very fearful. Linus is eleven years old and as the lump wasn’t visible on the x-rays, it could be anything from a peach-stone to a tumour.

As Dagny readied herself for surgery, I prepared Linus for the operation. The monitors attached, I was concerned to find that the oxygen levels in Linus’ blood were very low: not very surprising as I could see that his gums were pale, nothing like the fresh pink colour they are in a healthy dog. I turned the intravenous drip as fast as it would go, and kept the anaesthetic levels to a minimum as Dagny began to cut.

It didn’t take long for her to locate the lump, and it was immediately obvious that it was a foreign body and not a tumour. The gut was inflamed where whatever-it-was had already passed through. I opened up the set of special clamps and the  multiple packs of gauze I had ready and Dangy placed them around the gut to keep everything clean.

Pausing for a moment, she looked up and smiled. ‘What do you think?’ she asked. ‘I’m betting on a kongle!’ Kongle is Norwegian for pine cone. Her attention firmly back on her work , she cut carefully into the segment of intestine and drew out what proved indeed to be a section of pine cone. Poor Linus. No wonder it had been so painful.

From that point in the operation, it was obvious that things were improving. As Linus’ guts began to function again and the fluids from the drip got to work, his oxygen levels climbed from sixty-two right up into the high nineties, which is where they should be when everything is functioning well.

‘Would you mind just quickly going and telling his owners that it wasn’t a tumour?’ Dagny asked, as with the hole in the gut closed, she began to stitch the abdominal muscles. ‘They were so worried.’  As everything was stable, I was delighted to run through and tell them. What better Christmas present could there possibly be for me and them?

There are one or two things I find difficult about being an assistant. It’s not so easy for me to telephone owners and ask for an update, as I might do with one of my own patients. But I hope that the signs that I saw during that operation boded well for Linus and that he and his owners have had a wonderful Christmas together.

Merry Christmas everybody.