Rational use of resources in an emergency
Posted on 15 February 2013 by A consultant anaesthetist
‘I’m going first.’ ‘That’s not fair: you went first last week!’
‘Yes, but I’ll only be 10 minutes.’ ‘I don’t believe you. You always say that and then you take ages. I’m not falling for it this week.’
‘But it’s really important. It needs doing now.’
No, not my children squabbling over the laptop but a regular conversation, only slightly exaggerated, between surgeons on a Saturday morning as I begin my on call.
Anaesthetists are often expected to arbitrate. Having seen both patients, we can decide which one is the most urgent and should take priority in theatre.
Tensions run high because, at the weekends especially, a staffed operating theatre is a precious, finite resource.
I, too, find myself torn between doing semi-urgent cases because the theatre would otherwise be under-utilised versus keeping emergency theatre free for just that, the true emergency that crashes through the door unannounced. Should emergency theatre be used rationally, or rationed to those who truly need it there and then?
My attention was focused on this dilemma on one recent weekend.
A very elderly patient required a laparotomy for bowel obstruction. Conservative management was not helping and she took her place after the two other cases that the same surgical team wanted to do first. Our pre-op assessment was expedited by a crash call to attend when she had a series of acute deteriorations on the ward; she’d clearly remained peri-arrest and had probably suffered an intra-abdominal catastrophe.
I telephoned the awaiting consultant surgeon and explained the patient’s changed condition, and my feeling that it was now futile to operate. The surgeon agreed and the patient was moved to a side room for her remaining few hours to be made as comfortable as possible, in the presence of her family. Some junior members of the ‘team’ did not agree with this decision and felt that we were condemning her to certain death by withholding the chance of an operative cure.
I was still reflecting on the wisdom of my decision when I was called to help a colleague with a three-year old boy in extremis with acute severe asthma. The patient required immediate intubation and intensive care. Our ITU was full. The paediatric retrieval team was not quickly available. Together we took the child to the vacant emergency theatre, where he was swiftly and calmly stabilised by the on-call medical and nursing staff.
His parents were there throughout, with a theatre nurse to explain what was happening. We managed this young patient in our makeshift theatre-cum-PICU for five hours until he was collected by the paediatric intensive care retrieval service.
I felt our time and resources were well spent; I was pleased we’d been able to offer them when needed. I wondered what would have happened had we proceeded with the planned laparotomy. The young boy made a great recovery and was extubated 36 hours later. In the same hour, our elderly patient receiving palliative care passed away. I think the correct decisions were made that evening.
The author is a consultant anaesthetist
Ways of working
paediatrics and child health