July 09, 2007

Name: RN Clara Hart
Posting date: 7/9/07
Stationed in: a military hospital in the U.S.
Email: [email protected]

Fisticuffs was the name of the game today, or, as one anesthesia provider put it, "Rodeo Anesthesia." Today was the day I ducked flailing fists, kicking feet attached to powerful legs, and tried not to be head-butted by 6' 4" 230-lb soldiers. Twice! Twice I dodged punches, kicks and brain-rattling smacks.

I was looking forward to an "easy" day when I saw that my first patient was a ruptured eardrum repair. Most of the time we see these surgeries in our wounded who have experienced some type of blast: IED, RPG, or mortar. But as anesthesia rolled the stretcher into the bay and we put the oxygen mask on the patient, he began to flail. Fixing the anesthesiologist with a glare as I tried to hold his arm still so he wouldn't pull out his IV, I asked, "Is he OIF?"

"No," came the response. 

Reinforcements arrived in the form of several other nurses and tech, and we each attached ourselves to a limb in an attempt to keep him from further hurting himself and undoing his fresh surgical repair -- or taking one of us out.

Over and over we crooned to him, "You're in the recovery room, your surgery is all finished, you're OK." After continuing to fight us for several more minutes he slowly -- very, very slowly -- settled down.

The rest of the recovery went without incident, and when he was finally coherent and able to answer questions I asked him if he was OIF. "No," he responded, "I'm OEF, been home 2 months." Uh huh, I thought to myself, that explains it.

As he was transported down the hall I went in search of his wife. Once I found her and assured her he was doing well, I asked her about his deployment. She responded she didn't know much as he never spoke about it to her. I questioned her on her knowledge of PTSD, and referred her to websites where she could find additional information. As I walked her along in the direction her husband had gone, I gently reminded her that for any and all future surgical procedures she needed to tell the staff about his deployments. She told me she would, and thanked me for my help.

I no sooner returned to the recovery room than my next patient rolled out of the OR.  Striding to the bay, I grabbed the monitor cords only to notice this patient was also auditioning for rodeo anesthesia. I grabbed hold of his arm -- the one with the big cast on it, the one they had just completed surgery on, the same one he was trying to behead me with, yeah that one -- and all of us, anesthesia providers, pacu nurses and techs, again attached ourselves to various appendages. I looked at one of my coworkers and asked,"Is it a full moon?"

Another responded, "No Clara it's just you! They knew you hadn't been to the gym today and needed your workout."  We all cracked up at that and continued to hold on.

One of the techs managed to get a pulse ox on him so we could monitor his breathing and his heart rate.  He too, took some time to reorient.  Once he was awake and alert he was a wonderful patient with a wicked sense of humor. I asked the key question: "Have you been deployed?"

"Yeah," came the response, "finished my three tour seven months ago."

I simply nodded my head. I asked him if he'd had surgery before, and when he responded in the affirmative he asked "Why?  Did I get a little rowdy?"  After apologizing for fighting with us he seemed pleased to hear it took six of us to keep him from hurting himself or any one of us. I reminded him to tell the anesthesia providers of this anytime he had surgery. He agreed, apologizing some more. 

Over and over I have witnessed the OIF/OEF population emerge from anesthesia combative enough to do great damage to themselves or the staff. Again and again I have listened to their appalled lamentations once they fully awaken. Whether it is PTSD-related or just the disorientation that may come with emergence from anesthesia, very few really know. 

Too few people have a good understanding of PTSD (Post Traumatic Stress Disorder). With that in mind I would like to share this very short, very simple definition: PTSD is a normal reaction to extremely abnormal events. PTSD does not, repeating not mean you are crazy!  Even though it may seem like it, you are not losing your mind.

The following websites offer information and resources for helping to understand and overcome Post Traumatic Stress Disorder.

The VA's National Center for PTSD

Deployment Health Clinical Center


Thank you for the links. My husband is a Viet Nam era vet with (among other things) PTSD and, due to a series of stressful events within my life in the last few years, I think that I, too, am suffering from PTSD.

My husband has been home 3 weeks. Thank you for this. He's suffering short term memory loss, and is VERY embarrassed about it. I hope I can get him to read your post.

Thank you.

Clara--I very much enjoy your postings. I'm a Vietnam vet who has had Vietnam vet nurses as friends. I know from them that PTSD is something that nurses themselves are susceptible to, like combat medics.

So, take care of yourself and your fellow nurses. Your work as a nurse, and your postings here, are incredibly valuable. I salute all of you.

You always brighten my day, I know more now than I had and will try to be better for it. Thanks, maybe I am not as strange as I often thought.

Clara -- Thanks for what you do and your sharing with us.

What sorts of adjustments can the anesthetist do to help avoid these episodes, if they're expected or possible?

Best -- Gary

Hey US NAVY WIFE- Some of our guys have come back with memory issues as well. A number of things may be going on. Exposure to blasts VBID, IED or just your run of the mill HE. Poor sleep ueually about 3-4 hrs a night is good for memory issues. Or just plain old normal, your not crazy, people have been trying to kill you, combat stress. Take care of him.

I recently came across an AWESOME book titled "Down Range to Iraq and Back" by Bridget C. Cantrell and Chuck Dean. It is an excellent resource for anyone who has deployed or knows someone deployed. I urge everyone to make it a priority read! I would like to think this information helped someone!

Gary - to answer your question, we avoid using the drug ketamine in any OIF/OEF pt for anesthetic purposes. Unfortunately, unless we know ahead of time that the pt has had similiar reactions upon emergence from anesthesia there is little we can do other than make sure they don't injure themselves or anyone else.

Clara if you thought that was a good short read. Try Dav Groosman, US Army (Ret.)SF kind of guy. He wrote the forward to Downrange. His books are On Combat and On Killing. Big books are long in the tooth and chalk full of data and really great information way above Downrange. Another good read is Chris Hedges What Every Person Should Know About War. Its about the size and PEG rate of Downrange.

Clara, you need to document this in a letter to a prominent medical publication like JAMA, because medical practitioners and hospital adminsitrators will need to adjust incoming patient procedures to query for battle fatique and PSTD complications in sedation. This military blog doesn't go far enough in documenting this rising problem in our returning military soldiers and vets, where 1 in 3 will have mental/emotional trauma symptoms.

Here's a less clinical point of
May be a little easier to understand.

My name is Will Marshall, CRNA, and at 0436 on Thursday, 29 OCT, I just
finished placing a labor epidural. I came back to my call room and
continued looking for on-line anecdotal evidence of PTSD, specifically for
the anesthesia provider. I have been asked to present the subject for our
Washington State Association of Nurse Anesthetists meeting in the spring,
and I'm in the process of finding the required references.
I am a civilian CRNA, employed at Madigan Army Medical Center, Ft Lewis.
MANY of my patients are OIF / OEF, and for years now, I've been asking them
if they have any recent deployments, if they have anger issues, if they have
sleep disturbances, etc. If they answer in the affirmative, I make it a
point to tell the circulator and techs that we need quiet going to sleep,
and quiet (possibly with subdued lighting) during emergence. I also make it
a point to tell the PACU folks about it!
I am also an Air Force Reserve Lieutenant Colonel, and I returned just four
months ago from a six-month stint in Afghanistan. I've been having some
PTSD issues myself, manifested mostly by sleep disturbance/insomnia.
I want to thank you for your candid account of wrestling with your rodeo
anesthesia folks. I can't tell you how many times I've seen the very scene
that you describe!
Thanks for being the patient's advocate!

Will Marshall

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