Pink or Blue?

It was a few months after I’d started my anaesthetic training and I was slowly becoming more confident (and competent) about giving general anaesthetics safely. I was going a general surgical list and Dr James was the consultant anaesthetist in charge. Dr James said that she was going to “loosen the reins a little” and told me that I was going to look after this list by myself and that her role that morning was to “drink coffee and administer the occasional bollocking.”

So I got cracking and things were going well. True to her word, Dr James made various cameo appearances throughout the morning and “questioned” my choice of drugs and anaesthetic technique. The last man on the list was a 77yr-old with a few medical problems. Of all the people I had to put under that morning, he was the one I was most concerned about.

Anyway, I get him in the anaesthetic room, do all the per-op checks with the ODP (anaesthetic assistant) and get the monitors on. I put in a drip and set about getting him anaesthetised. I figured that he wouldn’t need much of my induction drug, so I slowly trickled in the propofol.
Despite my caution, things started to go wrong. After he became unconscious, I was able to bag-mask ventilate him OK and I after I put in the LMA, his chest was rising and falling, a sign that I was getting oxygen into his lungs. Despite this, the monitor was showing

O2 sats: 77%

And this is bad.

The ODP was a man called Edward, who was very experienced – in fact I believe he was set to retire in a couple of years’ time. Edward looks at me and says “Sats are low”

“I know,” I reply as I turn to oxygen up to 100%
“Is the LMA in properly?” he asks.
“I reckon so”
“Are you sure, I mean sats are only 75%! Do you want to take it out?”

I really didn’t think that this was an airway/ventilation problem and the fact that the blood pressure cuff was taking an awful long time to give me a reading made me think that the problem was that the patient didn’t have a blood pressure.

“No, leave it in,” I say.
Edward looks at me incredulously. “Well, what do you want to do?” he asks. “Shall I call for Dr James?”
“Yes, please do.”
Edwards kicks open the door to the operating theatre and yells at the theatre nurse to go and get Dr James NOW.

I look at the monitor again, it still says that the sats are 75% and, rather ominously, this mans heart rate had dropped from 70bpm to 45bpm.
“Edward. Squeeze this bag for me” I say and I open the cupboard to get out some emergency drugs. I pause for a second to consider which inotrope to use and at that moment, Dr James bursts into the anaesthetic room.

She looks at the patient then looks at me, then looks at the patient again then looks at me. “What’s going on?!” she exclaims.

“Hypotension… and bradycardia.” I mumble
She bags the patient and asks, “what have you got in your hand?”
“Atropine.”
“Ok, give 300mics”
I do so, and seconds later, the patient is better. Sats read 95% and the blood pressure is back to 133/58.
“How much propofol did you give?” Dr James asks me
I look at the syringe that is sitting on the anaesthetic machine. “105mg altogether”
“That’s not a great amount is it?”
“No, not really. I was actually really surprised that such a small dose had such a massive effect on this man”
Dr James shrugs and says “sometimes it happens like that.”

We get the patient through into the operating theatre and onto the theatre table. Dr James laments, “whenever I get called into the anaesthetic room, my first question is: ‘Pink or blue?’”

“Pink or blue? I’m confused”
“As in; ‘Is the patient pink or blue?’ This man…” she gesticulates at the patient on the operating table “was pink. So I knew things weren’t too bad.”

I mentally raise an eyebrow at this. I’m not sure how bad things have to be before Dr James gets worried.

“You did a good job,” she says and literally pats me on the back. “Carry on…” and with that she saunters back out of the operating room, presumably back to her coffee.

Edward and I look at each other and shrug as the surgeon starts the operation.