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I've been getting my ass kicked.
Little kids have been kicking my sorry butt all month long. You see, I've been doing the pediatric anesthesia rotation and getting a merciless beating daily.
I am a full-fledged board-certified internist. I have practiced emergency medicine for over three years. I've spent fourteen months as an anesthesia resident. Adults don't scare me. Sepsis, no sweat. Stab wound to the chest, been there, done that. Status epilepticus with an occluded airway, so what? Lethal tricyclic overdose, whatever.
Nevertheless, when confronting a 700 gram premature neonate undergoing repair of a congenital diaphragmatic hernia, I shake like a leaf from total terror.
Seven hundred grams. That's about a pound. When I was in college in Baltimore, there was a bar on Cold Spring Avenue that served one pound burgers. I used to wash them down with a few pounds of beer. Now I'm supposed to provide an anesthetic and life support for this burger of a human?
Are you kidding me?
Thankfully, my attending gives me very clear instructions: Fentanyl 10 - 30 micrograms per kilogram and pancuronium 0.1 milligrams per kilogram.
Let's see, that makes about 20 mcg of fentanyl and 70 mcg of pavulon. Gee, that's 0.4 cc of fentanyl and less than 0.1 cc of pavulon.
And fluid requirements: 4 cc per kilo per hour for maintenance, 6 cc per kilo per hour for third-space losses and 3 cc for every one cc of blood loss. Oh, and by the way, the entire blood volume is only about 60 cc. So, if the surgeons lose just 10 cc of blood on the way in, the kid may be toast. A few extra cc's of fluid and there's pulmonary edema and the kid's toast. And one air bubble in the tubing and the kid's toast.
Oh, and by the way, the endotracheal tube is a size 2.5. That's about half the diameter of a coffee stirring straw. I'm supposed to ventilate the kid through that? One little mucus booger in the tube and the kid's saturation goes from 100 to 50%, he brady's down to the 80's and then kid's toast.
Oh, and the room has to be kept at about 95 degrees so the kid doesn't get cold. If the kid gets cold he becomes acidemic and then he's toast again.
I cross my fingers and hope everything goes well. I sweat like a fat man in a sauna for two hours until, YES, WE HAVE WOUND CLOSURE AND THE KID'S NOT TOAST.
But wait, there's transport back up the to Neonatal ICU.
Graciously, the God whose existence I deny daily sees me through another day. Perhaps, He does this only to see the look on my face when I see the next morning's schedule: a one day-old undergoing repair of meningomyelocele in the prone position.
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