by Barbara Ebel
“A year ago. No, last night.”
Wilbur smiled as he placed his IV starting tools alongside her and pulled up a chair. He slipped a tourniquet on her forearm and slid a catheter into a hand vein as the nurse hung the IV bag. Annabel looked at the bespectacled resident with appreciation.
“My attending will be in to say hi, too,” Wilbur said. “We talked about your anesthesia already and I have your preop note right here. You’re totally healthy so your general anesthetic should go fine. As you know, I have to intubate you. You need the breathing tube in because your procedure requires you to be prone.”
“I know. Too bad the melanoma is way up there on the back of my arm so that I have to be turned over. I probably would have spotted it if it had been in the front.”
“Are you ready for visitors?” Robby said through the parted drape as Bob stood behind him.
“Yes. As ready as ever.”
“I can think of better ways to get out of work,” Robby said, walking in.
Annabel smiled. “But the team only gets rid of me for one day. I’ll be back tomorrow.”
Wilbur reached to the storage shelf below the stretcher and grabbed Annabel’s bag. “Your clothes are still down there,” he said, “but I’ll lock your bag up in the anesthesia office.”
“Thanks. You both are the best.”
Bob patted her hand. “I’ll be back when you get to the PACU. In the meantime, I’m going to help out with patients.”
Bob left and Wilbur stood holding a syringe with an orange label. “Okay if I give her some, Dr. Burk?”
“Sure. The room is ready. We’ll get started.”
Wilbur injected the amnestic into her IV and left. Annabel’s eyelids became heavy and what little anxiety she had dissipated. She glued her vision on her chief resident as long as she could while Robby took her hand and cupped it in his. How warm and comforting it felt.
“See you in the room,” he said. “You’re going to do fine.”
Before she knew it, a friendly orderly rolled the stretcher out of the cubicle as she clasped the white blanket the nurse had spread over her sheet. As she traveled down a long hallway, the untainted fluorescent fixtures above glared with bleach-white light and, after making a right turn, she heard running water hit the big aluminum sink for scrubbing. The sign above the double doors read ‘OR 9’ … her room. They had reserved it just for her.
Everyone inside seemed in a hurry. They lined her stretcher close to the OR table and she saw Wilbur’s face inverted above her, but Robby was also standing to her right. The blood pressure cuff tightened on her nonsurgical arm, someone slipped the white probe on a finger, and the EKG machine started beeping. She thought for a blurry second … how had they applied the pads and leads on her chest already?
“Good night, Dr. Tilson,” Wilbur said.
Breathing the strange-smelling oxygen coming from the rubbery mask covering her mouth and with her eyes already closed, Annabel felt a slight burning in her IV and then the voices drifted away.
After Wilbur inserted the breathing tube and secured it in place, the staff held the white sheet underneath her, picked it up, and magically deposited her face down on a pillow on the OR table.
-----
“Wake up, Dr. Tilson. You’re in the PACU.”
Annabel opened her eyes for a few seconds. A PACU nurse with kinky hair stood over her and fiddled with the pillow behind her head.
“There you are,” the woman said. “You did fine.”
“She’s going back to sleep,” she heard Bob say and then laugh. “Being students, we have to grab some shuteye whenever the opportunity presents itself.”
“Okay, I’ll be back to check on her,” Wilbur Gill said.
She swirled her tongue around her dry mouth and was happy to know the breathing tube had been removed. Wilbur and his attending doctor did a good job, she thought; she didn’t even have any pain.
Things quieted down again but she heard someone turn a page and realized Bob must be reading nearby, keeping a watch over her like Dr. Burk had suggested. She couldn’t be more grateful for how the group was treating her … Marlin Mack excluded.
The sleepiness she experienced trumped any bedtime tiredness. Maybe due to residual narcotics, she thought, or maybe the aftereffects of the inhalation agent Wilbur had taught her about. She felt carefree but then realized she didn’t know the results of the wide-excision Dr. Burk had done - or more importantly - if the cancer had spread to her lymph nodes. However, there would be plenty of time to hear all that and deal with it. She knew the results could alter her training and make her rethink medical school if she already had metastasis. For the time being, what she didn’t know was fine with her.
She thought about all her patients who had ended up in the PACU like her. At least her surgery had come at a better time than the last few weeks when she could have been subjected to the bad lot of neuromuscular blockers they had been giving. But a thought surfaced in her brain like the buildup of steam pressure near magma: The paralytic agents hadn’t been proven to be the culprit to cause re-paralysis; it was an assumption on their part. In reality, why would a drug which went away come back to cause the same effects? Of course, maybe it had a new metabolite, but that couldn’t be it since the victim’s blood work had the original compound. And she felt a little nervous when she grappled with the fact that the drug had a long track history of safety.
She grasped at everything Wilbur had told her during their time together at the head of the table. There were two parts of the equation to using the aminosteroids and other nondepolarizing neuromuscular blockers. One was the drug itself and the other was the reversal agent. Even if the blocking agent was almost gone at the end of the case, Wilbur had shown her the twitch monitor for the patient’s adductor pollicis in the hand or facial muscles which indicated how much residual paralysis was left … which indicated to him if he could then reverse it with his selection of reversal agent. She didn’t know the intricate pharmacology like the anesthesiologists did, but were they barking up the wrong tree? What if the reversal drug was the problem?
As she turned toward the right side where Bob thumbed through a surgery book, she discovered that thought to be a plausible possibility because by the time she tried to open her mouth, she already couldn’t speak.
-----
Robby stayed to the very end of Annabel’s case and applied dressings to her surgical areas. Then, along with Brandy Wallace and the OR staff, they turned her back over to a supine position on a stretcher that had been moved into the room. They watched as Wilbur and his attending made sure she had adequate head lift and, as she raised her hand to try and pull out her endotracheal tube, Wilbur did it for her. Her vital signs looked perfect so they all helped to take off her monitors.
Annabel’s chest rose up and down with good inspiratory effort and, as she continued to keep her eyes closed, Robby nodded to the anesthesia team. “Thanks, everyone,” he said. He patted his favorite student on her hand and walked out as they began pushing the stretcher out behind him. “And I’ll go take care of the surgical op note,” he told Brandy.
After writing a brief summary for the chart and after dictating the intraop note, Robby passed the OR front desk. The charge nurse rushed out the door after him.
“Dr. Burk,” she said, “Dr. Parker is looking for you.”
“Thanks,” he said. Since he was a few steps away from the anesthesia department, he went in wondering what the chairman of the department needed to speak to him about. Robby entered the first office on the left as Dr. Parker immediately rose from behind his desk.
“I was just calling you,” the elderly doctor said.
Robby continued into the room. “About?”
“The FDA called this morning. They’ve been working closely with the drug company that manufactures vecuronium bromide and rocuronium bromide and both agencies have tested the batches of drugs that were recalled. There is absolutely nothing wrong with them.”
&nb
sp; Robby ran his hand over his temple. “That’s a surprise.”
“That’s exactly what I thought,” Parker said.
“There has to be an explanation for what was going on. Did they mention anything else?”
“The FDA alluded to another possible drug problem but they’re not at liberty to say. Scientists are testing some possibilities right now.”
“Then, clinically, we’re right back where we started from.”
“Yes,” Dr. Parker said, “we could have another bad result at anytime. Like, heaven forbid, your patient who died after the redo inguinal hernia repair and the family lumping us all with a lawsuit.”
With raised eyebrows, Robby stared blankly. Another bad result at anytime.
“Excuse me,” Robby said. “I better go check on our own Dr. Tilson.” He spun around and fled out the door.
Chapter 26
Annabel wanted to scream out to Bob sitting right next to her, but she couldn’t speak or shout or move her vocal cords. As if her voice box was cemented in its last position, she became angrier and angrier that he sat right there and she couldn’t communicate. To get his attention, she decided to hit him but - to her horror - trying to do that was worse. She could not will any part of her body to make any movement whatsoever. In her own brain, she screamed to herself: I am totally paralyzed! The thoughts in her head escalated to a frenzy.
“Help me!” she silently yelled. “Stop what you’re doing and look here! I don’t want to leave in a body bag!”
But no one came into view. But why should they? Everyone was busy doing their thing and she was just a lowly medical student. If she ever disappeared, failed to show up, or died, the only thing they would miss about her was the scut work she contributed to the team. Maybe Marlin Mack would then appreciate her.
Her fear escalated to a feverish high. What a way to die, she realized. Like some ancient pharaoh encased in stone who died dead still. She was powerless and screaming silently for help but no aide was forthcoming. As she mentally gasped for air, none came and her thoughts spun around like leaves on a breeze. At least, if she died from asphyxia, she wished it had been something more exciting. Not due to some stupid drug problem but rather from drowning in some majestic blue lagoon in the Pacific Ocean.
As she became dizzy, she also wished she could see her family clearer in her mind and say good-bye. Inside her still-awake brain, the growing darkness then ebbed away into a slowly increasing illumination, like a dimmer-switch being turned up. A great happiness washed over her but, after the euphoria peaked, she glided closer and closer to brilliant sunshine and all consciousness stopped.
-----
Robby burst into the PACU heading straight for Annabel as Bob popped up out of his chair. Alarms sounded on her monitors and a nurse ran over. The three of them reached her in an instant.
“She’s not breathing,” Robby said. “Call anesthesia and respiratory.”
Bob ran to the OR doors and, on the other side, he shouted towards the desk. “Get anesthesia in here stat!”
Dr. Richie, the anesthesiologist running the day’s schedule, sped around the counter and followed Bob.
“Dr. Tilson,” Robby hollered, first giving her a shake. The pulse oximeter on her finger beeped loudly as her oxygen saturation plummeted lower.
As Dr. Richie pushed to the head of the stretcher and a therapist handed him an oxygen mask, he lifted her chin with his stubby arms, applied the mask, and gave her needed breaths. For a few seconds, her heart rate had slowed dramatically but as the oxygen carried itself through her lungs and into her bloodstream, her rhythm improved and the pulse oximeter reading went up.
With his scared expression fading, Bob said, “Dr. Burk, I thought I was going to have to give her a thump and start CPR.”
“I know,” Robby said.
“Look at her,” Dr. Richie said. “She’s stiff as a board.”
“It appears we have another postop paralysis case,” Robby said.
“We’ll check with my nerve stimulator in a moment,” Dr. Richie said. Without words being exchanged, he switched places with the respiratory therapist and prepared his equipment to intubate Annabel. After switching places again, he used a laryngoscope to open her mouth, view her vocal cords, and insert an endotracheal tube into her trachea. After verifying bilateral breath sounds, they hooked the tube to the ventilator.
After hooking up the nerve stimulator and giving it a try, the anesthesiologist looked at Robby and nodded. “Like we suspected.”
The doors opened again and Wilbur came running in with his clipboard. “Oh no,” he mumbled.
“We have things under control,” Robby said. “Can the four of us talk over here?”
The anesthesiologist gave Annabel an IV injection of more midazolam to help her forget the terrible occurrence and then he asked the therapist and nurse to stay with her. They walked over to the PACU central desk and sat down in a huddle.
“I don’t want Annabel hearing this,” Robby said.
“Exactly,” Dr. Richie said. “She’s hearing and knowing everything, that’s part of the horror of being paralyzed awake, especially during surgery. Hopefully what I just gave her is going to help sedate and relax her.”
Robby nodded. “I have an important update,” he said. “I just spoke with Dr. Parker. He had a conversation this morning with the FDA and, along with their dealings with the drug manufacturer, they have excluded the aminosteroid neuromuscular blockers as the responsible agents causing the postop problems we’re seeing.”
“It makes sense,” the anesthesiologist said. “So, Wilbur, what did you use intraop to paralyze Dr. Tilson?”
“One of them,” he said. “Rocuronium bromide.”
“They’re suspecting another drug,” Robby said. “Something different.”
“The reversal agent?” Wilbur said.
Dr. Richie, Robby, Bob, and Wilbur all stared at each other.
“But, again,” the anesthesiologist said, “we’re using tried and true dependable agents.” He glanced at Wilbur.
“Wait a minute,” Wilbur said. “I reversed Dr. Tilson with Legammadex.” He looked at the others imploringly. “As well as many other recent patients since the new drug came out.”
“Since it came out?” Robby asked.
“It’s a new neuromuscular blocking agent reversal, FDA-approved about two months ago. And it can only be used to reverse rocuronimum and vecuronium bromide.”
Robby and Bob looked at each other, and then Robby glanced over at Annabel. The monitors remained quiet and the ventilator continued doing its job.
“The drug is a modified gamma cyclodextrin,” the anesthesiologist said. “It’s unique in that it only forms a complex with rocuronimum and vecuronium, not our other muscle relaxants. Tell him,” he said, looking at Wilbur.
“So that complex,” Wilbur said, “reduces the amount of neuromuscular blocking agent available to bind to nicotinic cholinergic receptors in the neuromuscular junction. That results in the reversal of the blockade.”
“So,” Robby said, “since the incriminated cases had those two blockers, we’re onto something.”
“I’ve only been using the new drug with them,” Wilbur said.
“I know what we can do,” the anesthesiologist said. “Come on. I’ll explain.”
He rose and went over to Annabel as they all followed like students on a field trip.
Through thick glasses, Dr. Richie went to the nerve stimulator he had hooked to Annabel’s forearm and zapped it. He took a step back. “Okay, she was totally paralyzed but there is a small amount of spontaneous recovery now,” he said softly to the group. “We know Wilbur used Legammadex and that it reversed the muscle relaxant … at least for a short time. But then the action of the muscle relaxant came back.”
“Like the complex I mentioned broke down, leaving the muscle relaxant free to paralyze again,” Wilbur said.
“Exactly,” Dr. Richie replied. “So why don’t we try our old reversible
acetylcholinesterase inhibitor? The neuromuscular blocking reversal agent, Prostigmin?”
Their eyes all grew big and heads nodded in agreement. Dr. Richie stepped away to get the medication from an anesthesia drug cart.
Robby stepped alongside Annabel. “Dr. Tilson, you’re going to be okay. We’re all here with you.” He took her hand in his and affectionately squeezed.
“I’m here, too, Annabel,” Bob said as he leaned in close. “It may not seem like it, but we have your care under control. And I know we sometimes share a sense of humor, so wouldn’t you know it? It’s ODTAA.”
With a determined look, Dr. Richie returned wielding a syringe with a purple label and injected 3 milligrams of Prostigmin. They stood on either side of the stretcher. Waited and watched. Robby pulled up a chair and took Annabel’s right hand again.
“Squeeze my hand if and when you can,” he said.
He took a deep breath and fought back the emotion that was building for his student. What a mess this rotation has been for her, he thought. For the rest of her medical career, the black sheep of her training and the one with the most appalling memories will be his own specialty. He wished some or all of it could have been avoided and he knew he was partially at fault. He wouldn’t blame her if she quit medicine all together or even ended up flunking out. How could a student surmount the difficulties of a cancer diagnosis, Dr. Mack singling her out, surgery, and a near-death experience of being paralyzed awake, and then pass the rotation’s large final exam?
As Robby lowered his head, he felt a tiny flick of Annabel’s hand. And then another one.
“Dr. Tilson, it’s Wilbur. Come on, open your eyes.”
“Move a leg,” Bob said.
Annabel’s foot wiggled. Her left hand went up, followed slowly by her forearm as she gestured to the breathing tube. The pulse oximeter fell off and the nurse stuck it back on. She opened her eyes.
“If you can, Dr. Tilson, try to raise your head,” Dr. Richie said.
Robby held his breath waiting for the best possible result. She motioned forward an inch, then two. Her hand went further up and she pointed at the tube. With a determined look, she pulled her hand away as if telling them to yank the thing out.