In Connecticut in 1845, a dentist named Horace Wells watched a Barnum protégé demonstrate laughing gas. The performance convinced him that he’d found the means to pain-free dentistry. The day after, Wells inhaled nitrous oxide himself as a colleague pulled one of his teeth. Wells hastily arranged a public exhibition of the use and effect of inhaled nitrous oxide. Boston was selected as the site for his demonstration in December 1844. In a hall lost to history, Wells administered nitrous oxide to a medical student for the extraction of a tooth. Nevertheless, the student cried out in pain during the procedure. The idea of potency was not yet known; nitrous oxide lacks sufficient strength to create pain-free conditions for more invasive procedures. Wells was showered with ridicule for his failure and labeled a tarnished idol. He gave up dentistry, and the ensuing descent led to his 1848 addiction to another inhaled gas found to alter the senses, chloroform. Wells committed suicide in a New York prison after a deranged attack in which he poured acid on two women.
William Morton, a partner in dental practice with Wells, understood the significance of inhaling a gas to relieve procedural pain. With Wells’s failed demonstration, their partnership dissolved and Morton turned to a previous teacher, Charles T. Jackson, who advised him to try ether. After experimenting with ether—there is some debate as to how many patients he experimented on—Morton arranged for a public demonstration in 1846, also in Boston, of painless surgery to remove a jaw mass. But before his show, knowing the magnitude of his discovery, he first visited the patent office. His application described both the administration of a gas to produce insensibility to pain and the device used to present the gas to the patient. Morton had designed a glass vessel that contained a sponge soaked with the fluid ether and a wooden mouthpiece that extended from the vessel to the patient. Morton went to great lengths to ensure that his discovery was accurately documented, both in the newspapers and journals of the time, as well as legally.
Morton understood the advantage of nitrous oxide (that it was odorless) and the disadvantage (that it was too weak). He accepted the distinct and strong smell of ether because, unlike nitrous oxide, it rendered the patient unconscious. Morton not only tried to contain the odor in a flask so that others around might not recognize it, but he also disguised it by adding citrus oil to the ether.
On October 16, 1846, Morton conducted his demonstration on a patient named Edward Gilbert Abbott in the operating room of the Massachusetts General Hospital. When the patient breathed the gas, Morton announced to the surgeon: “Sir, your patient is ready.” Surgery commenced, and the patient did not react to the slash of the scalpel. When it was over, the surgeon, James Warren, turned to the audience and declared: “Gentlemen, this is no humbug.” The operating room used for the demonstration gained a new name that remains to this day, the Ether Dome, and it is now a declared historic site. The published paper announcing the arrival of painless surgery was not written by Morton or Warren, but by another surgeon observing the procedure, Henry Bigelow, who had helped arrange the demonstration.
Morton’s patent for what he called “Letheon” won approval. Morton chose the name from the River Lethe in Greek mythology; drinking the water of the river caused loss of memory. (The name seems to me too close to “lethal,” from the Latin letum, meaning “death,” but it didn’t matter.) The size and configuration of the Ether Dome placed many observers within reach of the patient and close enough to smell the gas. Those present at the demonstration saw through the deception and recognized the odor of ether, a readily available chemical. Further mention of the citrus oil disguise was dropped.
News of painless surgery after inhaling ether spread across the world with stunning speed. In an era before the Pony Express or the telegraph, it took only a few months following the Ether Dome demonstration for articles describing the discovery to show up in newspapers from Hawaii to Paris. The news traveled so fast and the use of ether became so frequent that Francis Plomley soon wrote an article in the British medical journal Lancet describing the stages of anesthesia—from too little inhaled gas, which left the patient giddily impaired but not yet ready for the scalpel; to excitation; to just right, allowing surgical anesthesia.
A month later, the term “anesthesia,” Greek for “without sensibility,” was coined in a letter to Morton by Oliver Wendell Holmes Sr.—the Boston poet, physician, and professor—and it stuck. “Letheon,” the name for ether listed by Morton on his patent application, didn’t.
AMANDA’S MOTHER, UNAWARE OF anesthesia’s history and unconvinced by the description of my process, remained dubious that I could induce a chemical coma in Amanda in a minute or less. She insisted on accompanying her daughter to the OR.
The gas I would use to anesthetize Amanda, sevoflurane, differs remarkably little from the ether used in 1846. Today’s gas has the same chemical backbone: four C’s (carbon) anchored by an O (oxygen). Instead of ten H’s (hydrogen), seven are replaced by jumping two letters to the left in the alphabet, to F (fluorine). In the 160 intervening years between ether and sevoflurane, many different gases were introduced, all with one or another undesirable trait and left to remain in historical context only. Sevoflurane is nonflammable, much less odorous than ether, and—most important—dramatically decreases the time until loss of consciousness. Two other volatile gases are commercially available—desflurane and isoflurane—but the properties of sevoflurane led to its popularity. (It appears we’ve reached the end of the line with volatile anesthetic gases; the ones in use today were all discovered decades ago and no new agents are forthcoming.)
Nitrous oxide, although not potent enough to use alone, is added because it provides a boost to the loss of sensation, and it does so without an unpleasant odor. I planned to start Amanda’s anesthetic experience by having her breathe nitrous oxide at fifty percent of the inhaled gas. Amanda would be shown a mask and asked to choose a scent—bubblegum, cherry, strawberry, or orange—which would be rubbed on the inside of the mask to cover the scent of the sevoflurane she would breathe. And she would have little to no recall for the odor of induction of anesthesia if I could convince her to breathe the nitrous oxide for thirty or so seconds before I added the potent sevoflurane.
The state of anesthesia is far different from sleep, but every day I find myself commenting to my patients and families on the process of “going to sleep.” During the induction of anesthesia, I advise patients: “Pick out a good dream. Do you have a happy place? Go there.” But there are no dreams under the influence of anesthesia.
Since I am not especially religious, it was decades after entering medicine before I suddenly saw a connection between the Bible and anesthesia. Genesis 2:21: “And Yahweh caused a deep sleep to fall upon Adam, and He took one of his ribs, and closed up the flesh.” Did Adam receive anesthesia for his rib resection?
To calmly anesthetize a child requires a skill set different from that needed to anesthetize an adult. An adult in the holding area will volunteer an arm, remain cooperative as the tourniquet tightens, and not flinch as the needle pierces the skin and enters a vein. Then, after a relaxing injection, it’s off to the procedure room for the countdown in reverse. I make it a little more challenging. As the intravenous anesthetic agent flows in, I suggest to start at 100 and count backward by 7’s. Making it to 93 is tough.
With a child in the holding room, just mention a shot and a struggle ensues.
I spoke to Amanda on the trip to the OR. Amanda’s mother followed. I pointed out the bees, butterflies, and birds painted on the walls and talked about her favorite colors. In the operating room, I continued to talk about breathing bubblegum, the scent she had chosen for the mask. As long as Amanda could remain calm, having her take several breaths of the gas that had failed Wells, nitrous oxide, would likely prevent her from remembering the odor of the potent anesthesia gas. Then we talked about a pretend trip to the zoo and smelling piggies.
“How many piggies do you smell?”
“Five piggies,” she said as she drifted into a st
ate of anesthesia quickly and quietly.
I turned to her mother and said: “She’s asleep.”
CHAPTER 2
Command Center
I WASN’T BORN A CONTROL FREAK. I GREW INTO ONE, and slowly at that. I was the typical teen, lackadaisical and rudderless, leaving a sloppy trail of uncompleted projects behind me. But today, within the nest of my anesthesia practice, I’m all about control. And I am always searching for ways to improve my care.
Many years ago, when I was just a year or so into my anesthesia training, a woman in her thirties lay on the OR table in front of me. Otherwise quite healthy, she possessed a lump in her neck, a thyroid nodule, that raised a ruckus by producing excess hormones—a condition termed thyrotoxicosis. She suffered from nervousness, fast heart rates, heat intolerance, and excessive perspiration. Her surgeon, Fast Eddie—the nickname he earned for his surgical prowess—approached the status of magician for the way he unzipped the thyroid gland from its home in the neck. In a teaching hospital, commonly a university-affiliated medical center, surgeons aren’t necessarily slaves to the clock. Residents, both in anesthesia and surgery, consume time. Slow-as-molasses surgeons who would flail about trying to succeed in a time-driven private practice find acceptance in these centers. So, Fast Eddie was an anomaly. That malfunctioning thyroid dropped into the pan in spectacular time.
Contemplating the end of my anesthesia care as the surgery neared completion, I pushed the contents of the syringe that I thought contained the drug intended to reverse the muscle paralysis, which I had injected at the start of the case. Then I noticed the wrong label on the syringe in my hands. My heart skipped a few beats. Syringes are wrapped with an identifying color-coded tape for the various types of drugs I use. The orange on the syringe I had injected indicated that the drug I’d just pushed wasn’t the reversal drug I had intended to use. It was relaxant, the paralyzing drug that I’d used at the start of the anesthesia. Before I could react and stop the IV, the drug flowed into my patient’s bloodstream. The unintended drug was safe, but it would keep my patient unable to breathe on her own for an extra hour before wearing off.
I had just executed the classic syringe swap, and I was the fool.
“Doctor Ed,” I said. “I just made a mistake that’s going to cost you some time.”
The surgeon stopped suturing the neck incision and looked up at me.
“I just reversed with relaxant.”
Fast Eddie understood. He raised his eyebrows, smirked visibly even through his mask, dropped his head back to the surgical field, and continued suturing. The worst of his response was that he didn’t say a word.
Now, as a complication, this wasn’t life threatening or even dangerous during this stage of my care. It added unnecessary time to the procedure and required me to breathe for my patient for that extra hour until the effect of the paralyzing drug wore off, but she didn’t suffer from my error. Still, to me my mistake was damning and painful. I had blundered. Letting down any proceduralist is beyond embarrassment; disappointing a superb clinician, someone practiced at perfection, is haunting. The enduring image of Fast Eddie’s expression found a permanent place in my memory vault. I recall the room, the time of day, and the surgeon. His look of disappointment is a frequent reminder not to err again.
After that I stepped back and contemplated my setup at length. This blunder ignited my transition to control freak. Previously, when instructed, I set up the room and learned by trial and error. I had no cheat sheet, no set of rules, no deep, thoughtful process. But humbled by error, I began a continuing education in process, quality, and critical-incident theory that continues to this day.
In my experience, a critical incident—in my anesthesia world, a “complication”—results from many smaller mistakes intersecting at a common point. For example, an anesthesia technician stocks the room, and a resident prepares for the case without confirming the technician’s work. A visitor to the OR, maybe a student, then trips and falls across the anesthesia circuit, disconnecting the patient from the ventilator. The resident evaluates the situation and concludes that the emergency resuscitation bag is the only manner to quickly restore breathing for the patient, but there is no resuscitation bag in the bottom drawer of the anesthesia cart. If the cart had been properly stocked by the technician, if the anesthesia resident had checked the cart, if the student had been more observant, or if the resident had guarded the anesthesia circuit from becoming dislodged—if any single miscue had not happened—the complication would not have occurred.
IT MAY SEEM A BIT of a reach to connect the contributions of Henry Ford to my medical career. He was not an inventor or scientist, but he was undeniably a great innovator, developing the concept of the production line as applied to building cars and setting the standard for the production of nearly everything today. In truth, the inventor of the production line was Ransom Olds, who patented the process of using an assembly line to mass-produce cars in 1901. A decade later, Ford expanded the concept to vastly increase production. His goal of supplying cars for the multitudes included a secondary gain of efficiency.
Quality measures freedom from error. A logical step after developing the production line was to measure how well it worked. Aside from the number of units built in a given amount of time, another measure of success is how well each unit is built. W. Edwards Deming proposed the first measures of quality in the post–World War II era, again applied to car manufacturing, as he developed fourteen key principles to improve quality. He used statistical methods to analyze for errors.
Analyzing the quality of a physician’s care of the human body using the standards of car manufacturing and Deming’s statistics was long considered impossible. The human body was thought to be far too complicated a system, composed of seven octillion cells functioning simultaneously, with any single cell able to fail. Cell functions seemed difficult to evaluate, and the reporting of symptoms was riddled with subjectivity. Relieving back pain, for example, might be considered a success at one medical center but a failure at another. In the mid-1980s, a federally funded RAND report published an equation for quality of health that included a variable for “full emotional well-being”—try putting a number on that—and concluded that “quality assurance is unlikely to grow in prominence.”
But around that time, Jeffrey B. Cooper, a pioneering engineer who researched patient safety, began showing that human error led to anesthesia mishaps and that “critical incident” theory could be applied to improve quality. The critical-incident concept entered anesthesiology with the realization that one big error culminated from the sum of numerous small mistakes. For example, if a patient doesn’t speak English, questions during a preoperative evaluation with the patient’s internist might be translated by a relative and the note then entered not in the medical record, but in a letter. At the hospital, the anesthesiologist’s pre-anesthesia evaluation could take place with a different translator. The evaluations might differ, and a previous anesthesia complication discussed with the internist might not be elicited by the anesthesiologist. If the internist’s note is not seen, a complication could occur.
Invoking efficiency standards to improve health care treads perilously close on the sanctity of life. It’s hard to accept that humans are merely a biological machine, although the most complex one in our world. Medicine might seem beyond applying the principles of a production line. But both manufacturing and medical procedures benefit from employing the same process, the same way, every time.
The solution to my syringe swap was intuitively simple: specify a distinct place for every one of the medications I use during the anesthesia process. For every patient, for every case, I draw into and label syringes the same way every time. No exceptions. I developed a set process for syringe placement, and the reversal agent is nowhere near the relaxant drug.
ONCE I STAND AT THE HEAD of the procedure table, it’s time for business. Searching for drugs or equipment in a moment of need indicates below-standard preparation. I must
be ready for any potential issues and pitfalls specific to the patient’s illness, condition, and intended procedure. I work under my own corollary of Murphy’s law: If you have it, you won’t need it. The addendum: Act expeditiously. The basic needs must be within an arm’s reach and not concealed in clutter. The anticipated is one step away; the potential, another step beyond. During anesthesia, efficiency correlates with economy of thoughts and movements.
The obsessive-compulsive in me materializes. With the diligence of a priest preparing for a service, altar and all, I prepare my space, equipment, and drug, clearing my mind, time, and energy to care for my patient.
I find nothing wrong with a preprocedure invocation. A short prayer or a moment of silence might seem an appropriate way to approach caring for every patient; after all, there is a good deal of faith in the practice of anesthesiology. The truth is, except in rare cases, I don’t pray—by which I mean I don’t rely on prayer. Or luck. Relying on luck in the procedure room is a bad choice.
Instead, I rely on a simple thought to gain focus, to be spot on. In the words of the screenwriter John Hughes in his movie The Great Outdoors: “Our Lady of Victory, pray for us.” “Game on” would work just as well. Invoking hope is left to those in waiting. I also envision: “Dancing fingers.” “Be the vein.” “Own the airway.” “See the whole picture.” “Observe the panoramic everything.” How quickly can the needles I place find the mark? How close to the target heart rate and blood pressure can I keep the patient? I am not searching for luck. I am striving for pinpoint skill.
Entering the procedure room is like entering a place of worship. The space is instantly recognizable, and its intended use clear. The procedure table sits in the room proper like an altar. The thick industrial poles that drop from the ceiling hold articulating arms ending in dome-shaped lights. These can be swung in multiple directions to focus on any point of the procedure table below. The table tends to be offset in the room, so that the head is closer to a wall than the foot. On the wall behind the head of the table, and sometimes hung from a ceiling-mounted boom, drop the pipes that carry the nonvolatile gases (pure oxygen, air, and nitrous oxide) used for anesthesia, in addition to a multitude of electrical outlets.
Counting Backwards Page 2