Yesterday was one long, tiring day. Got up at 5:20 am, got home to my hotel room around 6 pm. Too tired to do anything but lie there and read until I got sleepy around 10 and collapsed.

So much better today! On reflecting on my first day back in the OR since August, I noted no anxiety or feeling of uncertainty beyond my usual sense of alertness and vigilance which descends upon me whenever I enter the OR to work.

About three hours into the first case, the patient started to desaturate a bit and had mild tachycardia, which didn't seem related to anything that was going on. I watched with particular concern, and since I didn't know what was causing these changes, I did simple things to make them better without trying to figure out why they were happening.

My responses included:

1) turning off the nitrous oxide
2) increasing the inspired oxygen to 100%
3) adding isoflurane
4) giving more atracurium
5) giving more diprivan
6) giving more fentanyl
7) increasing the tidal volume
8) decreasing the respiratory rate

This worked: oxygen saturation improved and the tachycardia resolved. I had to do this twice more in the last hour of the case to keep things stable. She woke up fine; I'll never know what was going on back there.

The wonderful thing about experience is that you can do stuff like I did. The old adage, "For the beginner, there are many possibilities; for the expert, there are very few," is never truer than in the time-driven, stress-laden atmosphere of the operating theater.

It was so obvious to me what to do; in the early days or years of my career, in contrast, I would've driven myself crazy trying to figure out what was going on. It doesn't matter, is the lesson you learn after a long while. Except when it does.