Trust your routine

There’s a thing called arachnoiditis, which can be any number of varieties of badness, depending on how it’s caused, how quickly it is spotted, and who the poor victim happens to be, but if one thing is for sure, it’s never a good thing. The meninges ensheathing the tail end of the spinal cord become inflamed and subsequently adhese the cord to its surroundings, resulting in varying degrees of nerve damage, pain and loss of function. Worse case scenario you’re looking at debilitating pain, incontinence and paraplegia.

A spinal is basically a lumbar puncture, but instead of measuring, you inject local anaesthetic and analgesia

Theoretically speaking, one way of causing this sinister condition is if an anaesthetist, while doing their utmost to help alleviate a patient’s pain in labour, or to keep them comfortable during an operation, accidentally injects the wrong drug into their spinal canal.

So as you’d expect, my neurotic mess of a brain decided that the best time to remember this particular golden nugget of information was immediately after I’d injected the spinal anaesthesia into a very pleasant young pregnant lady and packed my equipment away into the bin, meaning I couldn’t triple check whether I had infact made a mistake. (I’d already double checked, obviously).

Clunk. Cue the hot rage and cold sweat trickling down my spine as I assumed I definitely screwed up, and thus began the mental torture – imagining the poor young lady confined to life in a wheelchair with a catheter as a result of my simple, stupid mistake. The brooding, omnipresent narrative of negativity reared its ugly head once again and began reeling through all the other times I’d made mistakes, be that in medicine or otherwise, just any evidence of my incompetence really, ferociously dragging them from the big mental bucket labelled ‘Failures’ and arranged them neatIy for my viewing pleasure. I immediately wanted to cry, punch the wall, run away, and go to sleep in roughly that order, but again – frowned upon in theatre with a patient on the table.

Throwback to when I first injected a frickin FLUSH after a cannula and panicked that I was going to kill the patient. Anxiety sucks.

This particular episode of anxious insanity lasted about five minutes until I got hold of my breathing, closed my eyes (there was another, more senior anaesthetist with me in the room, don’t worry) and calmly remined myself to trust my routine.

My routine is as follows:

  1. I’d scrubbed up correctly, and maintained sterility throughout the procedure
  2. I’d arranged my tray as I always do, and drawn up the drugs in the same order as I always do:
    • 10ml syringe with green needle to draw up the lidocaine (to numb the skin), then switched to orange needle, and laid crosswise on the plastic tray at the top.
    • 10ml syringe to draw up normal saline with filter needle, then injected into 10mg diamorphine powder vial, mixed and redrawn up to make 1mg/ml
    • Filter needle switched to 1ml syringe and used to draw up diamorphine solution to 0.5ml. 10ml syringe handed back to assistant.
    • Filter needle switched to 5ml GREEN-plunger syringe and diamorphine drawn up from 1ml syringe. Then heavy marcaine drawn up to final volume of approximately 2.5ml depending on patient’s size. Needle removed from syringe.
    • Square of white gauze laid down on drape next to tray, and green plunger syringe (for injection into spinal canal) laid diagonally on top, with no needle on it.
  3. I’d then draped the patient’s back which had already been sprayed (and allowed to dry) and found the anatomical landmark.
  4. I picked up my crosswise, black syringe with orange needle loaded, and injected local anaesthetic under the skin and into the start of the supraspinous ligament. I then took the syringe off the needle, leaving it in place to mark the location, and loaded the green sharp needle I’d used previously to draw up the lidocaine, onto the syringe.
  5. I injected the lidocaine into the ligaments, aspirating before injecting, and then took the syringe and needle out, returning them to the crosswise position on the tray.
  6. I inserted the introducer needle, and spinal needle, found the subarachnoid space, and picked up my diagonal, green, needle-less, 5ml, not-on-the-tray-but-on-the-white-bit-of-gauze-next-to-it syringe.
  7. I attached the syringe, confirmed CSF aspiration, and injected the solution.

This is the routine. I do it this way every, single, time. It is the only way that I can actually do this job without panicking every day and completely losing my mind. And you know what? It works. It’s not so much as a ‘coping mechanism’ as it is a safeguard, a backstop that will be there to catch me in my downward panic spiral and force me to realise that everything is actually alright. The reason it works is because of all the bits highlighted in bold. Every bold word adds another element of safety to the routine, meaning that I’m almost 100% guaranteed to notice if something isn’t quite right, before I do the final deed of injecting the drug.

So on this occasion, the only wrong thing I could have injected was the lidocaine, since this was the only other drug on my tray (I’d handed the diamorphine solution back to my assistant). Firstly, this isn’t the end of the world as lidocaine has previously been used for spinal anaesthesia, but it’s going out of fashion for its complications profile. Secondly, I could only have injected what was left of the lidocaine, which wasn’t very much at all. Thirdly, I would have had to have picked up the wrong coloured, wrong sized, wrongly oriented, wrongly located syringe, and then removed the green needle which shouldn’t be there, and pushed the wrong colour plunger the wrong distance, for me to have injected the wrong drug. I like to think at some point in this process some part of my brain would have triggered that something was up.

The only reason I was panicking on this occasion is because it was the first time I’d done a spinal in a pregnant woman for a C-section, in a new hospital, and I’d had a stressful drive in on the way to work. Fortunately I could reassure myself that I’d followed my routine, not noticed anything out of the ordinary, and that it was exceedingly unlikely that I’d made a mistake. Of course the operation went fine, patient was comfortable and I only lost about 600ml of sweat.

I was SO close to digging through the bin to try and reassure myself… but I didn’t.

As a learning point, I read this article about arachnoiditis which you might find interesting, which I found pretty reassuring, and it reminded me to ensure I’m spraying the patient’s back with 0.5% chlorhexidine rather than 2%, and really letting it dry before doing any needlework.

Thanks for joining me for another ramble – In summary:

For each procedure that makes you want to cry with anxiety, make aroutine, and stick to it. If you can add extra bits of redudancy that provide even more security, then great.

If you have any nice routines for procedures that you’d be willing to share to others, please feel free to comment below, and share the love!

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