🦸🏿🦸🏾♂️Heroes of the Week: Overcoming Obstacles and Making a Difference 🦸🏿♀️🦸🏿
Last Monday night, I was on call and prayed for easy spinals and chilled patients. But, as the saying goes, be careful what you wish for 💫. The night turned into an unforgettable adventure that tested my patience and skills to the limit🔥🔥🔥
I was called for a C-section for a very large lady with cephalopelvic disproportion (CPD) in labour, unable to be positioned, in a lot of pain, and bearing down🤰🏽. She arrived in theatre without a working drip, and finding a vein felt like searching for a needle in a haystack. After what felt like an eternity, I finally inserted a drip and then attempted the spinal. After 13 minutes of trying and failing, I quickly called my senior when I saw no light at the end of the tunnel. When help arrived, the drip I inserted came out, and we had to battle to get another one in🔫
The senior anaesthetist and I, with the help of six other people, finally managed to position her and get the spinal in using an extra-length black needle. The cerebrospinal fluid (CSF) was sluggish at first but eventually flowed nicely. The moment the spinal was in, the patient fell asleep, finally pain-free and 🥲 . But my nightmare wasn’t over yet. The next morning, I was questioned by Prof. Spijkerman because the obstetricians complained the spinal took too long, and the baby had low Apgars and risk for HIE 😭.. was post-call, miserable, and had a newfound PTSD for obese patients in labour ☹️⛈️
A week later, I thought I had finally blocked the ordeal from my memory. But, to my horror, I was hit with a consult Monday afternoon for the same patient. This time, she was re-admitted with a post-dural puncture headache! The nightmare continued 👻🌪️
I tried my best to find another cause for the headache, from meningitis to high blood pressure, but her history and symptoms were spot on: a severe headache worse on standing and relieved by lying down, accompanied by neck stiffness and photophobia. She fulfilled the criteria according to the IHS. Despite being on tramadol, Panado, fluids, and caffeine, she had no symptom resolution. I spoke to Prof. Spijkerman, and we agreed she needed a blood patch 🩸💉
This is where the heroes came in and saved the day. I messaged Dr. Mashavave and asked if he could kindly perform the blood patch. It had to be done in either theatre 3 or 7. I forgot to get consent from the patient, but Dr. Mashavave was kind enough to sort it out for me. I also informed Dr. Maladze-Tsanwani Tuesday morning that we needed a theatre and ensured the patient was fasted. All systems were go🦾 but unfortunately, I was stuck in theatre 9 and missed all the action 🫥
At around 11:30, I asked Dr. Mashavave how things went and if he won, and these were his words: “Yes. She had tears of joy immediately. Thanking everyone. She says she could not bathe at all and was smelling even. Could not stop thanking us. I think for the first time in anaesthesia, I felt I made a difference, though be it small. Hope she does not need to come back.” 🌻
When I asked if it was immediate relief, he replied, “It was immediate. Faster than an elective rocuronium dose taking effect.” 🚑
The challenges he faced were numerous: “First, you can’t see where the last spinal was done; there are no visible piercings. Secondly, she weighs 145 kg. Lots of soft tissue. Successful only on the third attempt. And by the way, the entire needle went in. 9 cm.”🦯
Dr. Mashavave was the hero who saved the day and finally put an end to my nightmare. I am so appreciative that he kindly agreed to do my patient, gave me no trouble when I asked and when I thanked him he said “No need to thank me. We are one department. It's like thanking your right hand for what your left did. You did what yu wer supposed to do. “ a humble and true hero !!
Of course, we cannot forget his sidekicks: Dr. Mashamba and Dr. Mokwene, for drawing the blood, and Dr. Tsheisi, for her moral support and words of encouragement!👯♀️
Thank you to these amazing colleagues for their dedication, skill, and teamwork. You all made a significant difference and truly embody the spirit of heroes in our department 🧨
also, baby was due for a discharge today and mum reports she is doing great 💜
Here are ten easy-to-read points about post-dural puncture headache (PDPH) based on information from NYSORA:
- Definition: PDPH is a headache that occurs after a dural puncture, commonly during procedures like spinal anesthesia or lumbar puncture
- Symptoms: It typically presents as a severe headache that worsens when sitting or standing and improves when lying down. Other symptoms can include neck stiffness, nausea, and photophobia (sensitivity to light)
- Onset: Symptoms usually begin within 24 to 48 hours after the dural puncture but can start as early as a few hours or as late as several days post-procedure
- Cause: The headache is caused by cerebrospinal fluid (CSF) leakage through the puncture site, leading to decreased CSF pressure and traction on pain-sensitive structures in the brain and spinal cord.
- Risk Factors: Younger patients, females, and those with a lower body mass index (BMI) are at higher risk. The use of larger needles or multiple punctures also increases the risk
- Diagnosis: Diagnosis is primarily clinical, based on the characteristic postural headache and history of recent dural puncture. Imaging is rarely needed unless other complications are suspected
- Conservative Treatment: Initial management includes bed rest, hydration, caffeine intake (oral or intravenous), and analgesics like acetaminophen or NSAIDs
- Definitive Treatment: An epidural blood patch is considered the gold standard for treating PDPH. It involves injecting the patient's blood into the epidural space at or near the puncture site to seal the leak and restore CSF pressure
- Procedure Success: The epidural blood patch has a high success rate, often providing immediate relief. However, a second patch may be necessary in some cases if the first one fails
- Prevention: Using smaller, non-cutting needles (like pencil-point needles) and minimizing the number of punctures can reduce the incidence of PDPH
For more detailed information, you can visit NYSORA directly.
