My Nursing colleagues reading this may recognize AORN (full legal name, AORN, Inc. and also known as the Association of periOperative Registered Nurses); actually, so may most of my readers. This is my professional association, or at least one of three and the one I’m notably actively involved in. Yesterday being Saturday was a day off of work, yet I found myself up early (not so early as a weekday) and off to Hospital.
AORN made arrangements with us to come and record a training video on a wonderful little thing known as Malignant Hyperthermia, or MH. Again, I expect my Nursing colleagues to recognize that, though potentially ... not. MH is a metabolic reaction to certain anesthetic gasses and some other medications which interferes with respiration (exhaled carbon dioxide is increased, because at the cellular level more CO2 is being released, but much of what is released is also converted to carboxymethhemaglobin, big word meaning Bad Things Happening), increases heart rate (trying to move off the buildup of CO2 and carboxymethhemaglobin). One of the last symptoms seen is a very rapid, very high fever, which does not respond to 'antipyretics' such as aspirin (for fever, right?) or stronger, and hence the name of the disease.
It’s known to include a genetic component; hence all family members of someone known to have MH are encouraged to be diagnosed, and to be educated to inform health care providers, specifically anesthesia providers, of this history. Because, you see, the absolute final symptom is death... and a rather difficult to reverse one at that.
So, Creator forbid you or yours ever need surgery, this is one question you (or yours) need to expect to be asked, even if only by the Perioperative Registered Nurse who will be caring for you during your surgery: Have you, or any member of your family, ever experienced or been told about MH?
Because if the answer is Yes, there’s a lot of things we can do to prevent an episode. First of all, we rarely use the specific gas anesthetics that cause MH any more. There are other medications which are implicated, though, so be aware. Also, as I tell my patients, one of the things you are paying that Periop RN for is their paranoia. Just because they (ME!) are paranoid doesn’t mean the world isn’t trying to kill the patient (YOU!) though, and so we think about those Worse Things That Could Happen and Make A Plan to prevent them, or deal with them if they do happen.
And MH? Well, as some of my Brit colleague friends say, “All very boring, don’t you know, really don’t want to go there.”
Since one of the aspects of the mission of AORN is provide the education and tools an RN needs to provide the best and safest care for patients, AORN came to Hospital to make this MH video. Why Hospital? Well, actually, in part because we are (at least somewhat) affiliated with Major University as well, and because of Sim Man.
Sim Man is the brainchild of one JS Gravenstein, professor emeritus of the University of Florida and former Chair of the Department of Anesthesia. He recounted an anecdote during an interview for this video about returning from a European trip in 1980. The aircraft he rode experienced a problem, the pilot informed the passengers that they were diverting for an emergency landing, and as JS looked out the window, he saw icebergs. Not the best of places to land, he thought.
The flight made it to Newfoundland, though, and landed at an air base. The crew then evacuated the passengers using those emergency slides out the doors, and JS remembers the flight attendant repeating, and helping the passengers, “Shoes off, jump and slide. Shoes off, jump and slide.” Impressed by their calm and focused natures during the emergency, he asked one of the flight attendants later (as they waited for ground transportation), how often she’d been in such a situation.
“Never,” came the reply. “This is my first. But we train for this in a simulator on a monthly basis.”
Well, said JS to himself, monthly training for difficult and life-threatening situations in a simulator. How often to we train in a simulator? Why...
And so he set about to design and build what became Sim Man. Sim Man is a CPR dummy, wired into a PC network which includes the anesthesia machine (ventilator, anesthetic gas nebulisers), monitors, IV and Arterial Lines (with a means to determine flow rates and medications administered), heart sounds and breath sounds, and a few more things I’m not completely aware of at this point. Bring in the trainee (we’ll say, because that’s the start of this idea, an anesthesia provider either MD or CRNA), and start a scenario, from anesthesia induction through emergence, and let them work through the process. And, every now and then, toss a monkey wrench (or two, or three... dozen) into the workings.
All without ever needing a real, live, actual human being to practice on.
Okay, all you role-playing gamers reading this. Got an idea where this is going? Uh Huh. You ought to.
So a crew of volunteers from Hospital, one of our Educators from AORN, and a couple of videographers from a company that AORN partners with for these productions hauled our gear downstairs to the Communicore and the Simulator Room, and set up to re-create a Malignant Hyperthermia Crisis. And in the review of the script process, your Correspondant was designated as the anesthesia provider. Someone said Anesthesia Resident, but I demurred... CRNA, thank you. Nurses Rule.
We ran through the scene the first time, cameras rolling, and all the expected things happened. Heart rate began to increase, slowly. First thoughts in this instance are usually, is the anesthetic getting light? Is the patient on the verge of being aware, and feeling the pain? Check the patient out, yes, the anesthetic gasses are flowing and being delivered at the expected dosage. The IV is patent, no problems.
Now the CO2 (measured by a capnograph which displays the levels of CO2 being breathed out) begins to rise. Aha! Airway problem? No, the endotracheal tube is in place and the breath sounds are equal and bilateral and so...
Check an arterial blood gas, and determine what are the blood levels of CO2 as well as that pesky aforementioned carboxymethhemoglobin. That, though takes a wee bit of time and...
The patient’s temp starts to trend upwards. OK. All other things being equal, it’s time to think MH.
And we got through the first run, and critiqued ourselves. Not much ‘chatter’ going on (if you’ve seen M.A.S.H., for instance, think of all the chatter going on while they do surgery. I usually tell folk who don’t believe that happens while Doctors and Nurses are Doing Surgery that the writers and actors toned things down for the TV censors), and a couple other things which the producers wanted worked in. So JS re-set the simulator, and we took our positions, and started again. Take Two.
More chatter this beep time, things moving beep along, everything’s hunky-dory, beep we’re all Happy beep Campers taking care beep of someone in beep surgery. I’m doing beep my RN thing beep years of experience beep in ICU as beep well as OR, beep scanning the monitors, beep hearing but tuning beep to the back beep channel the various beep sounds they make beep which every RN beep knows is what beep you do and beep know that everything’s beep hunky-dory and we’re beep all happy beep beep
Turn and scan the ECG monitor and gaze for an eternity that really could only be about a second and a half based on where that little squiggle was on the screen combined with the sweep speed of the display and ask myself:
Where in the hell did that PVC come from? (Premature Ventricular Contraction, or Omen of Really Bad Shit Gonna Happen) And right there, Oh My Readers, is when the simulation Ended for your Correspondent.
“I’m going to be fussing under the drapes a bit,” and under the drapes goes my hand and stethoscope to listen to heart sounds and sure enough there’s another lub dub dub... and the heart rate is trending upwards a bit. Check the anesthetic, is the patient getting light? No. Hey, the CO2 is trending upwards, how are the breath sounds? Equal and Bilateral. Is that CO2 reading real? Yes? No?
“S (our Circulator) I’m going to send a blood gas.” Right says S What’s your FiO2? (How much Oxygen are we pumping to the patient?) Everything OK asks the Surgeon?
“Well, she’s been stable and cruising, but I’ve gotten a couple PVC’s and her heart rate’s going up and so’s her CO2. We’re ventilating fine. How close are you to being done?” Pretty close. “You might want to move right along here.” And so they do, making it look like they’re hustling along. Surgeon asks, What did you use for anesthetic? “Isoflourane, so we’re OK with that. But... I did us succinocolinase for intubation.” And I’m watching the CO2 sloooowly rise, and then the graph on the trend gets a bit irregular, though rising...
“S, call for help, tell them to bring the MH cart, and to bring All The Ice In The Universe. We’ve got an MH crisis here.” And Surgeon commences to close the incision, and the MH cart comes in, and extra help with them, and we start the MH treatment process of Dantroline and
And there’s laughter, and ‘Good Work’ all around, and then Boy, T, you started sounding anxious there.
“Uh Huh, you betcha! And S, you just got SuperCoolCalm, eh?”
Well, yeah, that’s what I do says S, doesn't matter how excited anyone else gets in that room, I am the Blues Mamma here...
And then the Camera Guys re-set the cameras, and we shot a few individual parts of the scenario including the All The Ice In The Universe line, and the younger folk in the room laughed again but three of us (JS, S the RN from AORN, and Myself) didn’t and they looked at us and said, You’re Not Laughing.
"Well, because that’s one of the things about an MH crisis. You get to the point where the patient’s temp is spiking like that, and you get all the ice you can to pack around the patient. And you get it now."
So you mean all the ice in the machine in the Pump Room? Asks our fellow playing Surgeon, because In Real Life he’s one of our Patient Service Techs and runs about helping us do lots of things with patients.
“All of that ice, yes. And, all the ice out of the machine in Preop Holding. And all the ice in the machine in our Lounge. And from SICU. And CICU. And you call downstairs and tell Food Service, we need all your ice. All of it. And all the inpatient units. And before you’re done, you may be calling Gator Ice over there in town that you need deliveries Right Now.”
No way, says the youngsters. Way, says the three of us.
That’s when it dawned on me. The three of us, we’d experienced MH crises. And I was never, ever so thankful for Eunice, the RN Educator who oriented me to the OR and impressed upon me how serious MH is, and what to do about it as I was the day it happened. The rest of them, the majority in the room, they hadn’t. Because, you see, we’ve gotten that much better at detecting the susceptible patients, and preventing the crisis from occurring, and from dealing with it when it does happen.
And that, Oh My Readers, is a very good thing, because my Brit colleagues are right. It’s all very boring, and we don’t want to go there.
*CRNA: Certified Registered Nurse Anesthetist