While a patient sleeps, an anesthesiologist sits nearby in a chair in a
space bounded on three sides by the surgical drape, the anesthesia ma-
chine, and a large cart holding drugs and other equipment. Alone in his
makeshift cockpit, he listens to the rhythmic clatter of surgical instru-
ments and the incessant, irritating noise of the suction canisters. When
those sounds are combined with the smoke emanating from the electro-
cautery and the absence of happy chatter, the operating room exudes a
special kind of seriousness, as in a battlefield trench. Like the soldier, the anesthesiologist scans the world around him and waits for something bad
to happen—in the anesthesiologist’s case, blood loss or a drop in oxygen
levels. “Good” in anesthesiology means nothing more than the absence of
“bad.” The best an anesthesiologist can hope for is for nothing to happen at all. Often nothing is happening, giving the anesthesiologist time to stare about his world and lose himself in his personal problems.
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Having received a good general education in college, I imagined a
doctor as someone who moved easily between science and the human-
ities. Both my father and my grandfather had done so, although this
tended to be less true of doctors my age, which troubled me. In 1959, the English chemist and novelist C. P. Snow gave a lecture titled “The Two
Cultures,” in which he lamented the growing gulf between scientists and
literary people. Scientists had Newton, literary people had Shakespeare,
but by failing to cross over, each remained incomplete.
Sitting in my chair next to the head of my sleeping patient, I fantasized how anesthesiology might bridge the two cultures. True, the very nature
of operating room work seems to preclude the anesthesiologist from ex-
celling in life’s humanistic dimensions. The anesthesiologist has to deal with facts that are more specialized and immediate, less subtle and di-verse than those that confront most other doctors; they are facts that do not need an all-around intelligence to manage. Indeed, the most important trait in an anesthesiologist is not all-around intelligence but whether he or she panics during an emergency; thus, while it is hard for a great primary care doctor to be a narrow-minded person, an anesthesiologist who is
narrow-minded can be a great success. But anesthesiologists are perceptive. They have a perceptiveness of the universal kind. Their scrutinizing gaze passes through everything it meets with equal penetration. They can
guess a person’s weight to within a few pounds because they are so used
to calculating drug dosages by weight. By studying a patient’s pallor,
facial expression, pupil size, and degree of lip dryness, they can measure to a nicety a patient’s feelings. Anesthesiologists also possess a rare capacity: they can recognize that critical inflection point when sickness
passes into a death spiral.
But all my fantasizing came to nothing. At the bottom of my con-
sciousness I knew my humanities days were over. Patient needs soon
pulled me back into the present, and I forgot all about the subject.
A week after the meeting between the attendings and residents, as I sat
in the hospital cafeteria eating my lunch, my emergency beeper sounded,
telling me that a patient on one of the wards was in respiratory distress and needed to be intubated. Intubation involves putting a breathing tube
in a patient’s windpipe to assist his or her breathing, typically using a device called a laryngoscope, which has a metal blade with a light attached at the end of it. Once in place, the breathing tube is attached to a ventilator that forces air into the patient’s lungs. While the ventilator is
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being readied, the anesthesiologist, nurse, or respiratory therapist manually squeezes air into the patient’s lungs using an air-filled bag connected to the breathing tube.
I rushed to the patient’s room. I found an elderly woman sitting up-
right in bed, breathing fast and looking scared. I explained to her what I would be doing: lying her body flat, numbing her throat with lidocaine,
inserting a small device into her mouth, and placing a breathing tube to
help her breathe. She showed little interest in what I was saying, as all her energy was directed toward getting air into her lungs. I asked the nurse to tell respiratory therapy to bring over a ventilator, then I set my instruments out on the table to make sure I had everything I needed before
starting.
Within thirty seconds the patient started to tire out. Her mouth gulped
at the air ineffectually. I turned my eyes to her hands lying lifelessly
alongside her body and saw the nails flooding with a rosy blue. The nurse and I quickly lowered the head of the patient’s bed, allowing me to get to her airway. I applied a mask to her face and tried breathing for her with an Ambu bag, but it was difficult. The woman lost consciousness. I
quickly opened her mouth and, without bothering to numb her throat,
swept her tongue to the left side with my laryngoscope and inserted the
breathing tube into her trachea. That she did not fight me was evidence
that high levels of carbon dioxide had already built up in her body, an-
esthetizing her.
I listened to both sides of her chest to confirm the breathing tube’s
position. A few minutes later she regained consciousness and began to
fight against the tube. I sedated her, all while squeezing the bag to breathe for her. I impatiently asked the nurse when the ventilator would arrive.
She shrugged her shoulders and said she didn’t know. For the next fifteen minutes I squeezed the bag, roughly nine times a minute, approximating a
normal breathing rate. I could not increase speed or decrease speed with-
out causing a problem for the patient. The nurse darted out of the room
while I committed myself to my mechanical routine.
The nurse returned to say that no ventilators were available in the
hospital right now, but that one could be made ready in about an hour.
An hour! I was furious. But there was nothing I could do. No one else
was around to squeeze the bag. The nurse had to take care of two other
patients on the floor.
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Thirty minutes passed. Anger turned to boredom. I vaguely hoped for
something slightly out of the ordinary, but then quickly changed my
mind, as something out of the ordinary usually means an emergency for
an anesthesiologist. I began to yawn. The indifference of sleep possessed me.
Forty-five minutes . . . forty-six minutes . . . forty-seven minutes. The minutes passed on, and at the end of each one a caustic bitterness settled in my mind. I answered the question of what a doctor is. Is a doctor a
caregiver? A scientist? A technician? A gentleman? A bridge between
cultures?
No, a doctor is a bellows.
My answer dovetailed with uninvited memories that suddenly rushed
forward into my mind. We doctors have a saying: “What do they call a
person who graduates last in his or her medical school class? Answer:
‘Doctor.’” The educational process regards the best doctor as not much
better than the worst. Working off the principle of the least common
denominator, medical schools operate on the level of the trade school to
ensure that most students graduate. Students learn body parts the way
mechanics learn engine parts. They learn machines to test the
body the
way cable repairmen learn machines to test for bad connections. These
tasks do not require special creativity or any capacity for synthesis or
analysis.
Bored with this education—almost insulted by it—I had quietly re-
belled. During lectures I would sit in the back of the classroom and read the New York Times, purposely pushing the newspaper out toward the professor to let him know that nothing he said could be of any interest to me. I ignored the other medical students (although this left me feeling
lonely) and studied in the main library rather than in the medical library.
Later, while interviewing for internships, I met a doctor who told me how he spent his day “tricking the body”: if a patient’s blood pressure went
up, he pushed it down; if the blood pressure went down, he pushed it up. I left the interview feeling demoralized, thinking that all my education had prepared me to be nothing more than a handyman with a tire pump. Even
during residency I noticed that I, a trainee with a strong liberal arts education from an elite college, was in one room monitoring a sleeping patient, while another trainee with a communications major from a third-tier college was across the hall doing the same thing. I had taken a long, convo-
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luted path to the same end. The notion of “doctor as bellows” did not
seem that far off to me.
More than an hour after the intubation, a contrite respiratory therapist
wheeled a ventilator into the patient’s room. I hooked the patient’s
breathing tube onto the ventilator’s corrugated tubing, checked to make
sure the machine was delivering breaths, and left, feeling resentful. I felt particularly hurt because the real insult came from within.
Two weeks later I was back on the labor and delivery floor.
All labor and delivery floors emit a characteristic noise. To check a
baby’s heartbeat inside the womb, obstetricians once listened with a
stethoscope. Nowadays, the laboring mother typically wears a wide belt
attached to an electronic amplifier, which causes the baby’s heartbeat to roar continuously around the room and through the walls. To passersby
the heartbeat sounds like a strong horse galloping to its limits, its flanks sweating, its nostrils dilated, while the electrical static in the background sounds like distant gunfire. Taken together, the amplified heartbeats on a labor and delivery floor bring to mind a cavalry charge, the earth groaning heavily, crushed beneath a thousand hoofs going at full speed, afire
with frenzy—the battle for life.
I saw a group of nurses huddling outside a patient’s room. The room’s
electronic amplifier roared out a fetal heart rate slower than expected.
Sometimes a belt shifts position and captures the mother’s naturally slow-er heart rate, which sounds like a horse’s trot, but until this is proven the medical staff feels great anxiety, as a fetal heart rate less than 120 beats per minute means the baby lacks oxygen. As I entered the room I saw a
nurse furiously slide the Doppler over the patient’s stomach. She con-
firmed it was the baby’s heart rate. If the rate stayed low, we would have to perform an emergency cesarian section.
Fortunately, the normal galloping sound returned a minute later. But it
was a shot across the bow. I warned the mother that we could have
another problem later, and that we should place an epidural now, giving
her not only pain relief but also an alternative route for anesthesia in case of emergency cesarian section. Going to sleep while pregnant carries
some risk, I explained. The mother declined, noting that she had rods put in her spine as a teenager, for scoliosis. She didn’t want a needle touching
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her back. In truth, rods do make placement of a spinal or epidural diffi-
cult. I let the matter drop.
Three hours later, with the woman now fully dilated and pushing, the
electronic amplifier sounded another steep decline in the baby’s heart
rate. This time the heart rate stayed down. Suddenly the obstetrician
called out, “Cord prolapse!” The umbilical cord, which delivers oxygen
to the baby, had become compressed inside the mother’s birth canal. All
blood had stopped flowing through it. The team quickly stripped the
mother of her monitors and rushed her to the operating room for an
emergency cesarian section. Without umbilical blood flow the baby had
nine minutes to live.
The mother was already on the operating table when I arrived. Two
minutes had passed. I slapped some monitors on her body and told her we
had to go to sleep. “No!” she screamed. I thought she was just venting
anxiety, until I applied a black oxygen mask to her face in preparation for injecting Sodium Pentothal. She shook her head violently, trying to dodge it. “No! No!” she shouted. “I don’t want to go to sleep!”
“Why?” I asked.
“I’m afraid! Leave me be! I don’t want to go to sleep!” she screamed.
“But I have to put you to sleep. I don’t have time to try a spinal,” I
said.
“No! Do you hear me? I don’t want to go to sleep!” she furiously
replied.
Another minute passed. The baby had only six minutes of oxygen left.
I shopped for a different tone. I tried a relaxed and casual persona. I even took off my mask so that she could see me smiling. “It’s no big deal.
You’ll just take a nap, and then you’ll wake up and see your baby,” I said with sugary sweetness. But I smiled with an utter lack of confidence, and my fear only fed her fear. “No!” she kept shouting. My palms now sweating, I pleaded, “Please, let me put you to sleep.” The woman began to cry.
Hysteria passed into sadness and regret. “No,” she whimpered. “I’m
afraid, I’m afraid.”
Five minutes left. If only I could say the right thing! But my instincts
were poor. I had relied on books to learn the art of bedside manner, and, as with all things only superficially learned, I panicked when put to the test. I racked my brain trying to think of what to say and how much to
talk, how and when to look the woman in the face, and every second I
grew more afraid of saying the wrong thing or more than I ought, and the
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more I thought, the more confused I became, and in the end I kept my
mouth shut altogether.
“Put her to sleep!” roared the obstetrician, hovering over the woman’s
prepped abdomen, a scalpel in hand. “What are you waiting for?”
I was waiting for her consent. Did I need her consent? Yes, otherwise it would be assault, I thought. The woman has “rights” and “autonomy,”
all the words I had learned during my liberal arts education. She had said,
“No,” and no means no—at least in theory. If she had just given me some
wiggle room, if she had just said, “Well, maybe okay . . .” then I would
have slammed the Pentothal into her vein before she could have uttered a
qualifier. But she didn’t. Perhaps hysteria is crowding out her reason, I thought. If so, I could override her. Yet her fear was reasonable. I had told her before about the dangers of general anesthesia. I couldn’t in good
conscience say she was being irrational. So I did nothing. And yet doing
nothing was doing something: I was condemning her baby to death.
Life only intensifies that which is in a person to begin with, and in this case what was intensified in me was confusion. What is a doctor? I didn’t know. I might
as well have tried to explain the concept of the fifth
dimension. Is a doctor a technician who carries out his patient’s will? Or is he a judge who knows better than his patient? I had no answer. No
volume in the medical library had been titled “Nebulous.”
Three minutes left. Catastrophe loomed. Suddenly, Dr. S, who was the
anesthesiology attending on the labor and delivery floor that day, ran in.
Without breaking stride he reached for the syringe of Pentothal. “Put the mask on the patient’s face,” he said in a ringing, powerful voice.
“But she refuses general anesthesia,” I replied.
“Put the mask on her face,” Dr. S repeated with cold determination,
turning his thick neck and staring coldly at me.
I could not resist; the authoritative voice of command beat at my ear.
Besides, he had already started to inject the Pentothal. Without any extra oxygen the woman would turn blue when the drug hit her brain and
stopped her breathing. Dr. S had forced my hand. I was almost relieved.
The mask muffled the woman’s screams. Gradually the woman sur-
rendered to inexorable force, her cries of “No” waxing and waning as she
fell into unconsciousness, and sounding like a tea kettle on low. Once she was unconscious I did protest to Dr. S—to ease my conscience. I sum-marized what had happened and why I had delayed. Dr. S didn’t want to
hear it. “Doesn’t matter,” he declared, after following with a dose of
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muscle relaxant to facilitate the intubation. “Delay and you get a bad
baby.”
I intubated the mother. The obstetrician cut. A floppy baby boy
emerged from the woman’s abdomen a minute later. The obstetrician
quickly passed him over to the nurse, who roughly swaddled him to prod
him to take some breaths. A minute later the baby offered up a healthy
cry.
I tried again to explain my position to Dr. S. He ignored me. “It
doesn’t matter. You get a bad baby,” he said, dismissively. I made one
more attempt as he left the room, but all he said before exiting was, “You get a bad baby.”
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