For a brief moment I imagined myself somewhere else, magically
transported to another world without trouble. But the dream passed on
when I heard the deepening pitch of the pulse oximeter tone. When a
patient’s oxygen level is normal, the pulse oximeter twitters with a high, merry pitch and sounds like a bird happily trilling on a branch. But as a patient’s oxygen level falls, so, too, does the pitch, ominously, as though the bird were being slowly strangled. When I heard the change, my mind
raced: Why did I go down this path? You fool!
“Suffocation!” The thought darted through my mind. The sound of the
pulse oximeter grew distinct and menacing, a low and throbbing rumble,
like approaching thunder. The craft of anesthesia sometimes consists of
making oneself strongest at a certain point; one must choose a point of
attack and concentrate one’s forces there. I inserted the laryngoscope and lifted with all my strength, using both my arms, searching frantically for the windpipe. Still, I saw nothing. Panic took deeper root.
I made two more attempts at intubation. The patient’s face flowed
with blood and saliva. It felt to my fingers as though it were a stream of melting tar flowing toward the patient’s chest. I tried the mask again. I held the mask so tightly against the patient’s face that my hand started to cramp. The pain traveled up to the tense muscles of my forearm, but I
endured it without so much as moving my fingers, so desperate was I to
get even a smidgeon of air into the patient’s lungs. Still, no air made its way in.
My mind was frozen. Everything was frozen now, except for my right
hand, which just kept squeezing the bag.
Mournfully, I realized I had reached a major decision point, for unless
the muscle relaxant wore off in the next minute, and the patient started to breathe again on his own, the patient would suffer serious brain damage
or die. It is the most serious step in the career of any anesthesiologist: to tell a surgeon to perform a tracheotomy under emergency conditions,
which, at the very least, will leave a permanent testament to the crisis in
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the form of an ugly scar on the patient’s neck. Yet there may be no other way to get air into a patient before the muscle paralytic wears off.
I looked at the staff. The nurse’s eyes were popping. The surgical
tech’s mouth was wide open. The surgeon was agitated. His resident
assistant was pale. The moment of reckoning was at hand.
“Should I call another anesthesiologist to come help?” asked the
nurse. I said nothing. “Yes, I’ll go ahead and call,” she panted with
agitation. Deep down I knew it would accomplish nothing, because the
other anesthesiologist would likely have the same problem I had. In the
meantime, the patient would go that much longer without oxygen.
“I don’t want to do a trach if I don’t have to. Let’s wait a couple more
minutes. I bet the succinylcholine will wear off any second now,” said the surgeon with pretended self-assurance. I said nothing.
I had known all during my training that this moment would come; yet
I had always planned on having a serious conversation with myself about
what I would do, and somehow the time to do so had vanished into thin
air, like smoke escaping from a chimney. Nobody knew about this
planned conversation but me, and even I hadn’t thought about it very
often, occasionally at night, during a bout of insomnia. Yet I had counted on it, and now it was too late; there was no more time.
My hair fell over my brow, and with my dirty palm I brushed it back,
causing my cap to come off. I glanced at the blank, dying gaze of the
patient’s bloodshot eyes. Blood and saliva ran from the patient’s mouth
onto the pillow. I knew death was imminent; yet I deluded myself into
agreeing with the nurse, thinking that the right thing to do was to wait for help, as well as with the surgeon, thinking that while we waited the
patient would probably start to breathe again on his own. Hope against
hope—the unreasonable hope of the panic-stricken mind. Then I thought
about what people would say about me if they found out my patient
needed a trach. It would be an embarrassing admission of failure on my
part. Perhaps I should try intubating him one more time? Bit by bit, panic and fear were pushing me down a path, beaten out by many feet before
me, ending in impenetrable underbrush where even the smartest doctor
gets lost.
Suddenly, flashing through my head with the rapidity of lightning was
the image of the attending who had told me as a resident that I would
have to learn to eat shit and enjoy the taste of it, the one who had said that a doctor cannot be afraid. Next came the image of the cowboy-doctor
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who had called me a “chicken.” A doctor cannot fear what other people say when doing what he or she thinks is right, I thought. Then came the image of Dr. C, the monkey-turned-ass who had kept trying to intubate a
patient, almost killing her. No, a doctor does more than just keep trying to intubate, I thought. Then came the image of BSN, MSN, who had called the management of a medical crisis a “team activity” that demanded
“input from all parties,” who had talked like a senator, all while failing to produce the one thing that everyone wanted: a positive outcome. No, in a crisis someone must take command, I thought. Then followed the image of the patients who had tried to dictate their care to me—of the doctor’s wife, in particular, who would have been furious to be left with a tracheotomy scar on her perfect neck. Well, that’s too bad, I thought. An imperfect plan put into action at the right time is better than a perfect one accomplished too late.
My heart beat loud but evenly, driving through my body a new sense
of concentrated energy. Only to get air in! I thought. The one idea possessed me. I stared at the surgeon and ordered him to perform the trache-
otomy. The nurse seemed surprised. “What?” she asked. But the surgeon
sensed my determination and jumped into action. Within thirty seconds
the tracheotomy was in place. Air moved into the patient’s lungs.
We strained our ears waiting for the pulse oximeter’s pitch to rise in
sweetness. Ten seconds of painful suspense. It did rise, slowly. After
thirty seconds, it returned to normal. A happy, trilling chirp. So dear to the heart was the sound that all of us avidly listened without stirring, our faces still lime-white with residual fear.
The patient woke up and started breathing on his own five minutes
later. He was fine and had suffered no brain damage. Five short minutes,
and yet it might have made all the difference between a future life enjoying his children and grandchildren, and brain death.
But then the doubts returned. I kicked myself for having put the pa-
tient to sleep without a breathing tube in the first place. And I had regrets about his neck scar. My spirits had gone from being satisfied to being as foul and low as if I had been caught doing something awful. That night, I had a bad dream. I dreamed that I had paralyzed a patient with a muscle
relaxant, and then, as I reached for the anesthesia bag to breathe for the patient, I discovered that my hands were too heavy to do so, as though
they had been filled with lead. Then I saw that the bag itself was missing.
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The patient turned blue while I looked on helplessly. I called out indis-
tinctly in my sleep and trie
d to jump up.
The day after my near catastrophe a senior doctor approached me. I
had never liked him very much. He was always a little cold and stiff. I
feared he was going to berate me for what had happened. Instead, he said,
“I heard what happened yesterday. Good job, doctor.” Usually he ad-
dressed me by my first name, but this time he called me “doctor.” That,
plus his friendly tone, took me aback.
“But I blew it,” I shrugged. “My patient needed a trach.”
The senior doctor shook his head. “Being a doctor doesn’t mean being
perfect. All doctors make mistakes. And being a doctor isn’t about know-
ing the most science or being the best at procedures. Being a doctor
means knowing how to make decisions and take responsibility for them.
It means admitting that you and everyone else in the room are on the
wrong path, and getting them all back on the right path. It means giving a command and sticking to your guns. That’s what you did, doctor. Good
job,” he said.
I was still a little confused, but I was coming around. He knew I was
feeling better. He comfortably patted me on the back and said, “Don’t
worry. You know too much, you grow old too soon.” Then he walked
away. What an enormous part of a person’s nature is unknown to others, I thought as I watched him pass out of sight.
In fact, I did feel better, much better. When I left for home that eve-
ning, I felt for the first time in my life that I was a doctor. The feeling was infinitely satisfying; it wound itself pleasantly around me. I forgot about the monotony of medical practice. I forgot about being so harried at work that I had missed lunch again. I forgot about the fights I had had over the years with other doctors, nurses, patients, and hospital administrators. At that moment nothing mattered to me anymore. I looked through the car
window. In spite of the darkness, the air seemed to be shot through with
moonlight; in spite of the slow traffic and loud city noises, nature seemed eager to be set free. Yes, I knew I was a doctor, and I knew what a doctor was, and I knew where I was going, and I knew why I was going there.
My chest expanded, my heart pounded, and contentment raced at a gallop
through my veins.
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DEATH
I was in my last year of training. My patient was an eighty-year-old man
with terminal cancer, congestive heart failure, and a bowel obstruction,
now septic. In physiology, everything is coupled and connected, every
organ system hangs, lies, touches, and rubs, one piece on another. This
man’s organ systems were collapsing. When I met him in the holding area
he lacked the strength to speak, instead just gazing out onto the world
with sorrowful eyes. We wheeled him into the operating room and moved
him onto the table. I injected the drugs. Before losing consciousness, he looked up into my eyes, while I stared down into his. A flash of awareness seemed to register on the man’s face. Each of us recognized the vital import of what was about to happen. Then a black, noiseless emptiness
closed over the man, and the tie was broken.
More tumor had caused the bowel obstruction. The surgeon tried to
de-bulk it. An hour into the case, the EKG alarm went off. Tall, wild,
random markings tore the screen into jagged, angry pieces. A minute
later, I heard the inexpressibly mournful tone of an EKG gone flatline. I watched the surgeon hovering above the man bring his clenched hands
down on the patient’s chest. CPR. The room heard the sickening scrunch
of breaking ribs. The operating room team was unable to revive him.
I stared anxiously at the dead man’s body. Through the blue mesh cap,
I could see the patches of bald on the back of his head. I spotted the
wrinkled arm with its blood pressure cuff still squeezing in a futile search for a blood pressure. I stared at the man’s bloodless lips gleaming in the operating room lights, and the worn toenails.
In the dead “O” of his toothless mouth a savage groan was frozen stiff.
I tried to convince myself that it was really astonishment, not horror, that lay on the man’s face, that having just died he had seen the face of God.
But his glassy eyes stared out with seemingly sorrowful pensiveness, and
I realized that no one would look like that if they had seen God.
Sickness in a child evokes more sympathy than sickness in an old
man, as an old man has already lived his life. But the appearance of death is as terrible in an old man as in a child. The mouth moves no more, the
nose twitches no more—all this in someone who had once been dream-
ing, talking, and laughing.
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We covered the man so as little of death as possible would peep out. A
strange, hushed mood reigned in the room—the mood that comes at sig-
nificant moments sensed by all, if not entirely understood by all.
I went back to the anesthesia lounge, sat down, and shut my eyes. It’s
not often that a person sees the life of another finish its long arc in his own hands. I thought about how the man had stared up into my face
before losing consciousness. I somehow felt honored, having formed one
of the two boundaries of the man’s life. His first image may have been of the world before the age of the automobile; his last image had been of me.
Factual details, but vital; they hold a life together. It was as if fate had been guiding the man toward me all these years, every event in his life
moving him inexorably closer toward me, to its predestined endpoint.
Still, I didn’t really know the man. A beginning and end define a line, but not a life.
A patient death is a tragedy and never something that a doctor gets
used to. Yet even as late as the 1970s, when a patient died under an-
esthesia, it was reportedly not uncommon for anesthesiologists to have
said, “The patient took a bad anesthetic,” or “It was God’s will.” Such
doctors were distinguished by a certain emotional—no, not deafness, that
would be too strong—by a certain emotional imprecision; it was as if
some vaguely anxious thought about the dead patient had dawned on the
threshold of their consciousness but didn’t quite dawn. The attitude in
those days seems to have been that sometimes an unexpected patient
death comes just as it is, without any obligation for blame attached, or at least without any obligation to blame in any particularly cumbersome
fashion. Today, of course, an unexpected patient death automatically triggers blame and a lawsuit. People no longer assume that death comes just
as it is.
It’s hard to comprehend the detached sensibility of that earlier era. For anesthesiologists of the past, maybe the fact that their patients were already asleep let them adjust more easily to the passage from life to death, given how they were already predisposed to accept death as a common
occurrence. Frightful is the moment of passage from life to death—in an
awake patient. The dying person falls or sputters or fights for air; there is a final struggle; and only afterward does the end come. Anesthetized
patients, by contrast, are already still.
Yet this grudging acceptance of death seems to have existed beyond
anesthesiology and even beyond medicine. Elderly people have told me
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stories of how family members died under anesthesia in the middle of the
last ce
ntury. When I ask for details, they confess ignorance, as no investigation was ever conducted. Growing angry on their behalf, I offer to
review any old operating room records to see what went wrong. Instead
of thanking me, these people stare at me quizzically and say, “Why both-
er? You can’t change anything anyway. These things just happen.” I
assume the angry feeling in me is also inside them, absolutely invisible
from the outside, but still there. Yet it is not there. To this day, in my effort to gauge the significance of their blunted feeling toward the death of a loved one, it is hard for me to know whether to pity or admire them.
I’ve never had a healthy patient die unexpectedly in the operating
room. But I know that if such a thing happened, I would be numb with
horror, with my own imaginings, and with what I would see as my own
guilt, my guilt alone. Compared to anesthesiologists of the past, or at least anesthesiologists of legend, I would behave like a neurotic idiot. Colleagues of mine have admitted they would behave similarly. Perhaps the
rarity of death in the operating room these days has sensitized doctors to the event. The death rate from anesthesia was 1 in 2,500 cases in the
1950s. Today it is 1 in 500,000 cases, even though far sicker patients are operated on now than before. A world where people rationalize an unexpected operating room death with the phrase “He took a bad anesthetic”
has vanished forever into limbo.
I look upon my nervous anxiety toward death as a serious weakness in
a doctor. Indeed, one reason I went into anesthesiology instead of surgery was that surgeons are usually responsible for breaking any bad news to
family members. I once gave anesthesia to a teenage boy who had been
rushed to the hospital with a gunshot wound to the head. He had bright
red hair that fell to the ground when shaved off for surgery. Barely clinging to life even before the operation, he died afterward in the recovery
room. When leaving the floor I saw a woman who must have been the
boy’s mother, waiting anxiously in the hall. She had the same red hair.
Thankfully, I was spared from having to tell her the awful news.
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