Counting
Backwards
A DOCTOR’S NOTES
ON ANESTHESIA
Henry Jay Przybylo, MD
W. W. NORTON & COMPANY
Independent Publishers Since 1923
NEW YORK LONDON
To my wife who taught me
how to love and how to live.
Who encouraged my growth and
was my every inspiration.
And who left me far too soon.
Sandy Przybylo d. October 19, 2015
Contents
Introduction
CHAPTER 1 A Deep Sleep
CHAPTER 2 Command Center
CHAPTER 3 The Five A’s
CHAPTER 4 Railroad Tracks
CHAPTER 5 Fear of the Mask
CHAPTER 6 Nothing by Mouth
CHAPTER 7 Heartbeats
CHAPTER 8 A Most Unusual Patient
CHAPTER 9 Errors Everlasting
CHAPTER 10 In Wait
CHAPTER 11 Paper Cranes
CHAPTER 12 A Brain Trapped in a Box
CHAPTER 13 See One, Do One, Teach One
CHAPTER 14 Reentry
CHAPTER 15 Safe Travels
Acknowledgments
A Note on Sources
Introduction
I AM AN ANESTHESIOLOGIST. I ERASE CONSCIOUSNESS, deny memories, steal time, immobilize the body; I alter heart rate, blood pressure, and breathing. And then I reverse these effects. I eliminate pain during a procedure, and prevent it afterwards. I care for sick people and I have saved lives, but it’s rare that I’m the actual healer. As an anesthesiologist, I do nearly all of my hands-on work behind automatic double doors, sequestered, allowing surgeons to cut, gastroenterologists to probe, cardiologists to stick. The patients I care for place their faith in me, but we’ve usually been introduced only a few minutes before, and they rarely remember my name after their surgery or procedure is completed.
I put people into a coma, and the medications I administer cause paralysis. Yet only a handful of times each year do patients or family members ask how anesthesia actually works. The truth is there is much about anesthesia that even modern science can’t yet explain. But I know, as sure as the sun rises in the morning, that when I add a gas to the inhaled breaths, loss of consciousness follows; and when I remove the gas, awareness returns. This is a harrowing responsibility, and one I never take for granted.
Forty million people in the United States undergo anesthesia every year. It is the most frequently performed medical procedure that entails risk to the patient. The anesthesiologist is ubiquitous but largely invisible. Before the slash of the scalpel, the insensibility to pain is taken for granted. More people, up to a hundred million per year, seek relief from pain, both acute and chronic. Pain is the most common human health issue.
As an anesthesiologist of more than thirty years’ experience, working in a come-one-come-all practice within a large university health care system, I have administered anesthesia more than thirty thousand times during my career. To newborn babies, to kids, to adults in the prime of life, to centenarians. To patients dealing with the most benign conditions (removing a skin mole or placing infection-clearing tubes in eardrums) and to those facing potentially fatal ones (clipping a cerebral artery aneurysm). I specialize in pediatric anesthesiology, caring for about a thousand children in an average year—from one-and-a-half-pound micropreemies with skin so new that the tissues and bones beneath are clearly visible, to massively obese teenagers.
Anesthesiologists don’t keep regular hours; our care and expertise are called upon at all times, from midday elective colonoscopies to middle-of-the-night emergency trauma. There’s always an on-call anesthesiologist ready to respond. Day in, day out, most of the waking hours of my life are spent in that cloistered place behind the automatic double doors.
Anesthesiology allows little of what was learned in medical school to be forgotten. Perhaps no other specialty remains as expansive or inclusive, covering all the basic sciences (anatomy, pathology, physiology, pharmacology) and all fields of clinical medicine (internal medicine, surgery, pediatrics, obstetrics, and even psychiatry), and interacting with every other conceivable specialty. On any given day, any page of the physiology, pathology, or pharmacy texts may need to be scoured for a reference. From the time we meet in the pre-anesthesia area until the point that, after the procedure is over, I’m assured my patient has returned to a state of comfort and is prepared to reunite with loved ones, I am the primary care physician. During my anesthesia care, I become the internist, the ob-gyn, the pediatrician. The child scheduled to have a skin mole removed might have a failing heart; the woman whose brain aneurysm has burst might also suffer the pain and deformities of rheumatoid arthritis. When things take a turn for the worse during a procedure, when the blood loss climbs or the heart rhythm goes awry, it’s left to the anesthesiologist to make life right.
Over 170 years ago, inhaling a gas was shown to render a person senseless and thereby allow invasive medical procedures. Health care exploded. The magnitude of this medical discovery remains obvious today. The number of patients receiving anesthesia grows every year. The renowned New England Journal of Medicine recently polled its readers to select the most important article the magazine had published in its distinguished history. The “resounding favorite” its readers settled on was the NEJM’s 1846 article by Henry Jacob Bigelow about the demonstration showing that inhaling ether allows for pain-free surgery. (“Anesthesia” as a term had not yet been coined.) This article, published just a few months after the historic demonstration at Mass General’s Ether Dome in Boston, bested every advance made since then, including the introduction of antisepsis, of X-ray imaging, and of antibiotics.
More than a century and a half later, I am unable to provide an answer when patients and families ask the most basic question of my specialty: how the gas I use anesthetizes. Despite decades of research, its mechanism of action remains a mystery. I must have faith in my anesthesia gas. It’s an irony of our work that patients and their loved ones place faith in the anesthesiologist, who in turn places faith in the gas. In many ways, I’m a faith healer.
I routinely ask patients to count backwards as the anesthesia medications are introduced. Counting backwards in this way is a time-honored anesthesiology tradition. When rapid-acting barbiturates were introduced half a century ago, making it possible to induce loss of consciousness in a matter of seconds, an anesthesiologist likely asked a patient to start at 100 and count back, curious to determine the speed of induction. 100 . . . 99 . . . 98 . . .
The practice stuck.
In my experience, patients never make it out of the 90s.
Counting Backwards
CHAPTER 1
A Deep Sleep
AMANDA NEEDED A DEEP SLEEP. A SLEEP LIKE no other that she had experienced in her five years of life. Breathing was difficult, her nose always congested. When she did sleep, she snored and her nose frequvently ran. A clump of tissue with the consistency of jam, the adenoids, blocked the breathing path through her nose. Her surgeon needed to pass large instruments through her mouth, beyond her tongue, and past her tonsils to scrape or burn—the exact technique the surgeon’s choice—the redundant adenoid tissue to open the path of air through her nose. The procedure required Amanda to remain still, open her mouth, and keep it open; to let the surgeon pass surgical instruments deep into her mouth; to not cough or gag; and to not scream or cry when the knife sliced the adenoids out. To make all this possible, Amanda needed the deep sleep of anesthesia.
Amanda knelt on the gurney, her toes peeking out from under her bottom. She leaned forward, elbows on the mattress, contentedly coloring the paper in front of her, unaware of what was to come. I don
’t think she even noticed me when I entered her pre-anesthesia space. Her parents, standing to the side of the gurney, appeared trapped in tight quarters and couldn’t disguise the fear on their faces. How would I place their daughter under the influence of my gas, and would it be safe?
“In the thousands of cases in my career, my anesthetic has never failed. It’s one hundred percent effective,” I said. The look in their eyes changed slightly, but I didn’t have their complete confidence yet.
The health care buzzword of the day is “transparency.” Describe every treatment option, all the benefits and possible complications, then let the patient, or in Amanda’s case her parents, make the decision. I’ve signed consents for procedures for others—my kids and wife. No greater stress in life exists than making decisions—decisions with possible lifelong implications—for another person, even if you brought that person into this world. That stress increases as the procedure approaches, and the more I say, the less my patients and their families hear. Patients come to me for my insight and expertise. They want to know what I recommend. They want to know what I would do for myself or my family. Many don’t want to make a decision, especially one they are not well versed in. Amanda’s parents didn’t understand anesthesia or my intended process. I explained my plan as plainly as possible.
“It’s as simple as this. From the time I pass through those doors,” I said, gesturing to the sliding glass doors of the prep room, “until the time she’s asleep will take less than two minutes. The mask goes on and it takes only eight to ten breaths.”
Amanda’s parents probed for assurance and confidence.
“If there’s a problem, it’s mine. You come to me. I’m the one responsible for anything that might go wrong. And I don’t like problems, so there won’t be any.”
I mentioned that I would love to etch a guarantee in granite, but I can’t. I added: “In all the thousands of my cases, a healthy patient goes in, a healthy patient comes out.”
A look of amazement swept over their faces.
“At the end of the surgery, I turn my gas off, Amanda breathes fresh air, and the anesthesia wears off. Technically, she’s awake when she leaves the room, but recognition takes a few minutes. She’ll be in recovery when she understands where she is. As soon as that happens, you’ll rejoin her.”
In all, from the time I first meet patients, families, and loved ones until the trip to the anesthetizing area begins takes about three minutes. In that time, I need to earn their trust and have them place their faith in my care.
Soon, Amanda would be in the procedure room breathing a combination of gases on her way to entering the state of anesthesia.
A MAGIC PILL THAT RELAXES, soothes, comforts, prevents all pain, staves off bad dreams and thoughts, and provides a cooperative patient during medical procedures. Such a magic pill is the pharmaceutical industry’s ultimate fantasy. In reality, it’s already been found, and it’s not a pill and it’s not natural. It’s a gas that’s synthesized.
A volatile is a fluid that in air at room temperature would rather exist as a gas. Volatiles are part of everyday life. They are components of cleaning fluids, bleach, paint, nail polish remover, and, most important for me, my anesthesia gases. The term “volatile anesthesia” means breathing a gas to induce the anesthetic state. Ether is one such volatile that loves to become a gas. Its magical benefit to health care—painless surgery—was first shown in the 1840s, but its history goes much farther back in time.
The Muslim cleric and alchemist Jabir Ibn Hayyan, who lived in Persia in the eighth century, likely came close to synthesizing ether. He is known to have used the components needed to synthesize it, including sulfur, which is necessary to create the reaction with alcohol. But it remains speculation that Jabir actually managed to produce ether. (Jabir was a remarkable man regardless of his role in synthesizing ether. As a noted philosopher, geographer, and linguist, he is said to have written some three thousand books. The Latin form of Jabir is “Geber,” and his prolific and wide-ranging writing is considered by experts in etymology to have inspired the word “gibberish.”)
In 1540, Valerius Cordus, a German physician, botanist, and alchemist whose life was only a flash—he was twenty-nine when he died—combined fortified wine and sulfuric acid to form what he called oleum dulce vitrioli, the delicious Renaissance Latin term translated as “sweet oil of vitriol.” Its medicinal properties were noted and came to be of even greater interest when Cordus’s contemporary Paracelsus, the Swiss-German polymath, found that ether caused chickens to sleep. Paracelsus is believed to have tested ether to treat seizures, the result unclear. He might have gone on to discover the painless state created by the sweet oil of vitriol, allowing for surgical invasions of the body, but he, too, died prematurely and mysteriously.
Another two centuries passed before the German-born chemist August Sigmund Frobenius published an article in 1729 describing the method of synthesizing oleum dolce vitrioli and calling it “ether,” from the Greek base word meaning “to alight” or “to blaze” (ether is very flammable). Ether also connotes the upper air, which is fitting because it is a volatile that readily changes from liquid to gas.
Near this time, pneumatic medicine—inhaling gases as a means of therapy—flourished, leading to the discovery of the euphoria one can attain by inhaling the fumes of ether. Medical students, then as today, searched for new means to distract themselves from the pyretic intensity of their work and found that “ether frolics” provided that relief.
Medical cures of the time weren’t founded in science and included treating asthma with dried, ground toad; holding a live puppy to the stomach to deal with bowel obstructions; applying leeches to bleed bad humors; and using dog feces as a remedy for sore throat. But as alchemy—the belief of transforming one compound into another, such as lead into gold—evolved into chemistry, the individual gases composing air (oxygen, nitrogen, and carbon dioxide) were isolated. Joseph Priestley, a chemist and noted grammarian—he wrote The Rudiments of English Grammar—produced nitrous oxide for the first time in 1772. By 1800, the chemist Humphry Davy had noted that this colorless and odorless gas caused a state of euphoria and might even be used to prevent pain during surgery. He didn’t pursue that purpose. By the turn of the century, nitrous oxide demonstrations for comic relief had become a business.
In the 1830s, Samuel Colt, under the name of the “Celebrated Dr. Coult of New York, London and Calcutta,” demonstrated the effects of nitrous oxide, then encouraged audience participation, for twenty-five cents per man. He advertised with a poster declaring “A Grand Exhibition . . . Laughing Gas. Laugh, Sing, Dance, Speak or Fight” and used his profits to develop the Colt revolver. In New York a few years later, P. T. Barnum opened Barnum’s American Museum, where visitors could test laughing gas. Traveling shows charged “gentlemen of the first respectability only,” although one poster included a drawing of a woman, for the chance to inhale this gas that offered short-lasting, non-alcohol-altered sensory impairment, with no hangover.
IT WAS 1839 IN RURAL GEORGIA, and a slave was forced to inhale the vapor of ether as onlookers sought to have him dance while impaired. The prank ran sour when the slave boy—whose name was never recorded—passed out for an extended time. Frightened, the partygoers summoned a doctor, who observed the boy until the ether wore off with no apparent ill effect. The intention of such forced ether frolics appears to have been not to lose consciousness, but to stumble uncontrollably for the amusement of the observers. Word of the misadventure spread to other doctors in the area.
Near the same time, a Georgia doctor trained in Pennsylvania, Crawford Long, brought ether frolics to his own community. Long is thought to have known of the 1839 incident, which set the foundation for what followed. In Long’s own words: “In the month of Dec. 1841, or in Jan. 1842, the subject of the inhalation of nitrous oxide gas was introduced in a company of young men assembled at night in the village of Jefferson, Ga., and the party requested me to prepare them some. I
informed them I had not the requisite apparatus for preparing or preserving the gas, but that I had an article (sul. ether) which would produce equally exhilarating effects and was as safe.” After the effects of the inhaled ether wore off, Long noticed new scrapes and bruises that he couldn’t explain. He observed others sustaining cuts and bruises without reaction while under the influence of the gas.
An acquaintance of Long, a young man named James M. Venable of Jackson County, Georgia, found himself in the right place at the right time and in the right company. A few months shy of his twentieth birthday, he sought out Long’s advice regarding a lump on his neck. Long advised that the lump be surgically removed. Venable dreaded pain, but Long assured him that the lump could be removed without it. On March 30, 1842, Long folded a towel, saturated it with ether, covered Venable’s mouth and nose, and instructed him to breathe. Minutes later, Venable emerged from unconsciousness proclaiming he felt no discomfort, as the resected mass sat in a surgical pan. It was the first known use of inhaled ether to enable safe, painless surgery.
Long did not document the event at the time. He did, however, record the two-dollar charge for ether—the first known bill for providing painless surgery. Long, and his family and colleagues, later offered plausible excuses for his failure to publish and establish his claim. He lived twenty miles from the nearest published paper and several times farther from the closest medical college. He believed he would need to report on a series of cases, not just a single patient, to merit publication. And at just twenty-nine, he doubted that his veracity would be accepted by elder physicians. A deep sleep removing all senses from a person was also perceived as sacrilegious at the time. An unnamed clergyman later decreed: “Anesthesia is a decoy of Satan . . . rob God of the deep earnest cries which arise in a time of trouble.” In rural Georgia, Long might just have been right to hold his secret near and dear to himself.
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