This is the time when I observe the surgeon’s qualities and abilities. It was during an interlude that I recognized perhaps the greatest surgeon I’ve ever worked with. Watching Casey perform surgery was like seeing an old master’s brushstrokes. Casey’s hands flowed through a surgical field like an artist’s brush across a canvas. I saw him think as he developed new uses for the standard instruments. As Casey’s hands with knife and scissors dissected tissues, he laid out the anatomy for any observer to witness. He was a surgical magician. He taught me anatomy and technique.
VITAL SIGNS FOR SOME CASES are prone to roller-coaster rises and plunges. One of my most memorable cases, perhaps my most difficult case, was providing anesthesia for a man’s liver tumor resection. A tricked-out IV pole—a rapid intravenous infusion device—helped save the patient. The liver is notoriously vascular, and tumors only worsen the situation. As I watched, I noticed that every time the surgeon’s hands touched the liver, blood welled out of the belly. Besting the surgeon’s attempt to drain the patient’s body of blood, the rapid-infusing IV device replaced the patient’s blood volume and sustained his blood pressure throughout this marathon procedure.
The infuser consists of a three-by-five-inch box bolted to the IV pole at a height of about five feet. The main unit contains a liquid-based fluid warmer and pump that pressurizes two separate chambers hung from above. A bellows in these chambers inflates and squeezes fluid out of the plastic bag under pressure, sending the warmed fluids through the IV tubing to the patient at a rate that exceeds most surgeons’ ability at bloodletting.
Shortly before the advent of anesthesia, the practice of providing fluid directly to the veins was begun to offset the dehydration resulting from cholera’s profuse watery diarrhea, a frequent cause of death. Sterile fluids for intravenous administration were introduced in the 1930s, and later came improved catheters and tubing. The rapid infuser allows fluids and blood to flow to the patient at high rates while both warming the fluid and preventing the inadvertent injection of air, which can create a lethal airlock inside the heart.
During the unforgettable tumor resection I watched, I lost count of how many times I saw the surgeon’s hands touch the man’s liver, or of how many units of blood I transfused. Despite my best efforts, the patient’s vital signs drifted low. I added medications that boosted the heart and squeezed the blood vessels, but still the trend was in the wrong direction. After a few hours of this battle, and with the patient’s temperature dropping, I turned to the surgeon and told him: “Put your instruments down and step back from the table. Go away; I’ll call you back when I’m ready.”
I needed time to adequately resuscitate the patient, to replenish the patient’s blood volume, and to correct the labs. The surgeon listened to me. A half hour later, I called him back into the OR—the patient now stable, all the numbers normalized (the temperature was still a little low, but I would correct that more slowly)—and the anesthesia record returned to railroad tracks. The patient survived the procedure, but I don’t know whether he survived the tumor over the long term. The case ended late at night, and I couldn’t get to bed fast enough. This was a rocky interlude saved by technology. In that OR, I was the one who was drained—of energy.
The interlude is normally uneventful, but always uncomfortable and, in some cases, nerve-racking. But in my anesthesia nest, I can always touch my patient, which provides me some sense of security.
CHAPTER 5
Fear of the Mask
I FIRST MET AMY BY THE SOLES OF HER FEET.
She’d been assigned bed space 4 in the “sandbox,” a space adjacent to the operating rooms that serves as a pre-anesthesia staging area in the pediatric center. A nursing station overlooks the area, which is about twenty feet square—big enough for three patient carts. The front is open, while the back is a wall of windows, allowing freely flowing light and a view. Three equal-sized spaces occupy the sides, with carts separated by ceiling-hung sliding drapes that stop about a foot from the floor.
Privacy is nil. The edges of the drapes never close completely, and there is no way to have a private discussion. But the sense of all being in this together pervades. No one ever complains about the lack of privacy, and almost all are cheery, proving that bigger isn’t always better. This area is the result of the old building having been remodeled multiple times, in an attempt to maintain pace with evolving technology and the changing needs of health care.
Amy was ten, and I had been warned that she was a little “high-strung.” Armed with this information, I raced into the sandbox with the tails of my gray lab coat flying behind me, my right hand as usual wrapped around a rolled-up paper surgical hat just removed and stuffed into the waist pocket.
Entering Amy’s space required that I walk past it to the windows, to find the edge of the privacy curtain. I pulled it back and found her cart empty. Aside from some personal belongings, there was no Amy, and no family. In no more than a second, possibly two, before I could even scan the area, I heard her mother.
“Amy! Amy, you get back in here! Amy!” There was a momentary pause as her mother caught her breath. “Amy, you’re embarrassing me! Amy!”
I cocked my head to the right but still saw nobody. Then I leaned to the left and saw Amy’s mother squatting on the other side of the cart.
“Amy, you get back in here!” her mother said.
The bottom of Amy’s feet came into view, her toes to the floor. In an infantryman’s low crawl position, with her wrists hidden under her chest, her elbows jutting out to her sides alternating thrusts while staying low to the ground, she was attempting to snake her body along the floor, as if maneuvering under barbed wire. My gaze continued up Amy’s back, which ended abruptly at her shoulders, as her head and neck disappeared under the curtain. She was trying to slide into the next patient space. Her mother’s hands were firmly wrapped around Amy’s ankles, preventing the escape, and I heard her mother grunt as, with a great heave, Amy was yanked back to her designated space. Her mother then hoisted Amy up and plopped her on the cart.
The pleading look that Amy shot at her mother was unmistakable. Amy was prepared to do anything to get out of her situation.
“Hi. I’m Doctor Jay. I’m the anesthesiologist.”
“Oh boy,” was Amy’s mother’s only response.
ANESTHESIOLOGY IS A SPECIALTY that is normally nontherapeutic. I provide the assistance that allows the treatment. The “Do no harm” motto of Hippocrates weighs heavily on me. Providing safe care for the child is the only issue more important than easing anxiety before anesthesia is induced. If a perfect pre-anesthesia sedative medication existed, every child—and parents on an as-needed basis (and they almost always need it)—would receive it. There is no such medication. And, children often are unable to swallow pills. The alternative is an elixir that is frequently spit out or vomited at the start of anesthesia. For some kids, the only alternative is an injection of a sedative, and then they cry for the two minutes it would take me to induce anesthesia by mask and gas. I prefer to use little premedication and lots of nonstop talking until the child is unconscious.
My patients are not always willing participants, and I’m often viewed as the one forcing their participation. I’m the last physician a patient interacts with prior to losing consciousness. Placing a mask for the induction of anesthesia, sometimes against the will of the child, can be tricky. Older children and adults reflexively push the mask away when it is first introduced. Claustrophobia and a feeling of suffocation, despite plenty of gas flow, are the common complaints. The anesthesia mask may induce fright; a phobia of the mask, an unreasonable fear, may develop.
Phobias hold lifelong implications, of course. And it’s reasonable to assume that the face mask I use to induce anesthesia could create a phobia, as it is the last memory prior to any invasive and extensive surgery. But I have never received a complaint that the anesthesia experience negatively and irrevocably altered a child’s behavior. And no psychiatrist, to the best of my
knowledge, has ever come forward questioning the psychological impact of my anesthesia care on a child patient.
My concern motivated me to study children with anesthesia mask phobias. Rarely does a child volunteer fear of the anesthesia face mask before a procedure. And not one of the phobic children I’ve encountered has ever been able to describe the moment—or the procedure—when the fear developed. Mention receiving an injection, a shot, before anesthesia, and most children freak. Fear of the hypodermic needle is real and pervasive. When given the option, children always choose “going to sleep with the mask” over an injection. Anesthesiologist colleagues (not parents) have told me about alterations in certain children’s behavior following a procedure that required anesthesia: refusing to accept any lollipop after being given a lollipop sedative; rejecting all cherry popsicles after use of a cherry-scented mask; insisting on having a nightlight on at all times in the bedroom. In the last case, I remain curious about whether the boy in question was told “Lights out” at the induction of anesthesia.
SINCE EVERY STEP TAKEN toward a procedure room increases the anxiety of my patient, my goal is to shorten or disguise the time from that first step until my anesthesia coma is induced. Distraction is a major tool, and maintaining an ability to distract keeps me young, or at least requires that I stay current and informed. Bands, books, TV shows, personalities, the latest news and, even better, the latest gossip—I have to know it all.
I met Adam when he was twelve, that miserable middle-school age. Tweeners are never easy to connect with. Add a necessary medical procedure on a testicle or penis, and the situation turns unbearable for all. The time from first meeting the tweener until I steal consciousness cannot be too short.
At that age, life fluctuates with every passing second. A changing body collides with expanding maturity and raging hormones, and the result does not always make sense. Whispers from friends and classmates as a procedure approaches outpace these growing minds, and this is the age of proliferating horror stories. “Did you hear about the boy who had a mole removed? He was an honors student before, but not anymore.” Such utter nonsense is passed between these kids, only adding to their anxiety.
For Adam, making matters worse (or at least more sensitive), the procedure would be on one of the most intimate parts of his body. The left side of his scrotum was twice the size of his right side. As a boy develops in the womb, his testicles form in the belly, then descend into the scrotum. This path does not always seal tightly or strongly, and sometimes the lining of the belly—the peritoneum—slides through this tract, causing a bulge often seen in the scrotum; the result is an inguinal hernia. A loop of bowel might become trapped, or peritoneal fluid might accumulate—the latter known as a hydrocele. Surgery is required to close the path.
Sometimes the testicle doesn’t reach its final destination in the scrotum (an undescended testicle), and surgery (an orchidopexy) is needed to make a path and pass it to where it belongs. For twelve-year-old Adam, this surgery on his manhood was not a pleasant thought—and embarrassing, to say the least.
Adam was a bit chunky—a challenge for placing a pain relief block accurately. He didn’t appear athletic, and he spoke technogeek. As soon as we were out of hearing range from his mother, seeking to distract him on the way to the OR, I wanted to ask my usual question concerning girlfriends but was leery; I was unsure if he had reached this stage. I asked anyway.
“So Adam, what’s the name of your girlfriend?” I was more direct than usual.
“I don’t have a girlfriend.”
“What grade are you in?”
“Sixth.”
“Sure, you have a girlfriend. What’s her name?”
“I don’t have a girlfriend.”
We approached the OR door without Adam having a clue how far we had traveled.
“Adam, I think you do have a girlfriend. What’s her name?”
“I don’t have a girlfriend. But if I did, I’d call her Madame X.”
“Aha! Busted.” Now inside the OR, I stopped his cart short of the procedure table.
“Adam, first, I know you have a girlfriend. And second, you need to know that what’s said in the OR stays in the OR. Nobody but us will ever know. Just fess up.”
The OR nurses chimed in: “Yes, Adam. That’s right. Nothing leaves the OR. And he’s not going to leave you alone.”
“Adam, just give it up. You’ll feel so much better. Just tell us her name.”
There was a pause. Then he said: “Sarah.”
Adam, for all I knew, might have made this name up just to end the discussion. Still, with my goal accomplished, Adam was distracted and quickly asleep, and calmly so.
Surgery was uneventful. I placed a nerve block for postanesthesia pain relief, and Adam left the OR with a balanced scrotum of equal size.
An hour later, I walked over to the outpatient center to check on him and determine the effectiveness of my nerve block. I saw him sitting up on his cart watching TV. I knew my block had worked. As I entered his room, where his mother sat near his feet, Adam noticed me, and his eyes grew wide. A worried look came over his face.
“Remember,” his voice cracked.
“Remember what?”
“Remember,” he said again, slightly louder and more demanding.
“Remember what?” I said a bit more firmly, and gave him a subtle wink.
“Remem . . . Ohhhh.”
“What are you two talking about?” his mother asked.
What’s said in the OR stays in the OR. With that I began to turn away, but caught a glimpse of the wink that Adam sent back my way.
If Adam looked back on his trip to the OR, he would be unable to estimate how long in distance or time his journey to anesthesia was. Distraction had removed him from his surroundings and anxiety. Adam didn’t need any medication before heading to his procedure—especially a medication that could potentially make recovery more difficult.
HIGH-STRUNG AMY SUFFERED from fibular hemimelia, a bony defect of her leg. The lower leg consists of two bones, the tibia (shinbone) and the fibula, a narrow bone to the lateral side. The fibula, fragile in appearance and non-weight-bearing, is the lateral buttress of the ankle, stabilizing the ankle and allowing the foot to plant flatly when walking. Hemimelia is the congenital absence of one of the bones of a distal limb—in Amy’s case, the fibula. Without it, lateral support for the ankle is lacking and the foot rolls in, the sole facing sideways, the inner ankle contacting the floor. Amy had what is now known as longitudinal hypoplasia of the lower extremity. Simply stated, for as yet unknown reasons, her fibula had not fully developed. She was left with a bowed shinbone and an unstable foot. I didn’t notice any crutches near Amy, so I’m not sure how Amy got around.
Injustices of life come in many manners and on many levels. Twenty thousand single gene defects, give or take a few, cause a wide array of abnormalities, and then there are all the congenital defects, which are not genetically inherited. Amy’s defect was nasty and disfiguring—but not necessarily damning. Amy’s life would be altered, but not shortened. She would not be a ballerina, but she might write the score. She might not be a runner, but she could be a sports physician. Neither her life nor her intellect was ever at risk. She required multiple surgeries because the plan was to attempt to salvage her leg, as opposed to amputating it.
Prior to our meeting, Amy had undergone multiple surgeries and was well aware of her circumstances. I never drew out whether she had had a negative experience. She knew she was going to have another surgery that would cause pain and discomfort, and once again would be incapacitated for a prolonged time. She was spunky, insightful, and right. This was happening again.
“Oh my God; I can’t believe I’m doing this.” That was Amy’s response to my every question, and always uttered in a high, squeaky voice. That was her dirge even when I didn’t ask a question.
Yet Amy surprised me by how cooperative she became. She was indeed “a little high-strung,” but she answered all my q
uestions and allowed my examination without complaint.
“I’m sorry. I’m so embarrassed,” her mother lamented.
I looked across the cart, over Amy, to her mother, arched my eyebrows high, and flashed a wide, closed-mouth smile. “We’ll be OK,” I said. I couldn’t hold Amy responsible for all she had been through, but her mother seemed to be holding herself too responsible for Amy’s defect and behavior.
Then Amy, her mother, and I discussed the possible sedation medications I could prescribe before her surgery, to help her become calm. I explained that the best way to ensure the effectiveness of the medication was through an intramuscular injection.
“A shot!”
Amy quickly pointed out that the operating room was a better alternative to receiving a shot.
“No way. I’m not getting a shot.” There was no doubt in my mind that if I approached her with a hypodermic needle in hand, I’d be treated to the vision of Amy’s back becoming smaller and smaller as she ran away as best as she could.
“OK. No shot. The other choice is to drink some medicine. We dose it safely, so you still might remember the start of the anesthesia. There are a couple of side effects, just to inform you fully.”
“What are they?” asked Amy’s mother.
“First, there’s a chance the anxiety might be worse when she emerges from anesthesia.”
“She can become more anxious?” Her mother spoke in a tone somewhere near disbelief.
Counting Backwards Page 5