“Second, there’s a higher incidence of nausea and vomiting after the procedure.”
“You mean I might throw up?” Amy said.
Amy’s mother was quick to point out that Amy had not vomited before. Together they chose to forgo any pre-anesthesia medication.
While I could reassure her mother that all would be well, there was no assuring Amy of anything of this nature.
“Oh my God; I can’t believe I’m doing this. Oh my God . . . ”
“OK. Time to go,” I said.
Amy, sitting on the cart with its back elevated so that she could relax and see more than the ceiling, turned to her left and grabbed her mother’s arm. “Mommy, please. Mommy!”
“Amy, the sooner this happens, the sooner it will be over. You’ll be fine.”
Amy’s mother pried her arm free, and without further hesitation, I rolled the cart out of the sandbox and toward the operating room. Amy had seemingly resigned herself to her fate. There were no more attempts to delay the procedure; no jumping-off-the-cart escape attempts. She sat back, crossed her arms across her chest, and pouted.
But every ten feet or so as the cart rolled along the hall to the OR, Amy leaned forward and pleaded: “Oh my God; I can’t believe I’m doing this. Oh my God; I can’t believe I’m doing this.” Unfortunately—for Amy more than me—her case was scheduled in the OR that was farthest from the sandbox, prolonging the time until she was anesthetized. So I heard her moan over and over again. It was always a couplet. Once in the room, I moved like lightning and Amy was quickly anesthetized. To my surprise, Amy accepted the anesthesia mask. There were just more moans.
The surgical goal was to start lengthening the tibia, and this wasn’t the final corrective procedure. Amy would return to the OR.
After Amy was awake in the recovery unit, I spoke with her mother. I wasn’t displeased with myself, but I wasn’t happy either. I felt I hadn’t done enough to help Amy with her anxiety. You might have knocked me over with a feather when her mother asked if I would be amenable to caring for Amy when she returned for another procedure.
A strange thought coursed through my mind: If this was, in her mother’s mind, a success, what might Amy have been like before?
“We need to do something better to make this easier for Amy next time,” I said.
“Thank you. Thank you. Thank you.”
Amy’s anxiety bothered me. My goal was to alleviate the stress, have a peaceful separation from her mother, create a state of calm on the ride back to the OR, and—maybe asking a bit too much—have Amy smile. To me, it’s disconcerting, bordering on painful, when a patient is noticeably stressed during this time. I was driven to make Amy’s next experience better.
Several months later, I received a phone call from Amy’s mother. Her recovery from our first procedure together had been fine; there were no complications, and the pain was not bad. This time, Amy and her family allowed me to order some medication that could be used before they entered the hospital. Amy swallowed a Valium tab as they drove into the hospital parking garage; the timing was intended to allow the medication to take effect and calm Amy at the point she most needed it, as the OR time approached. There were no under-the-curtain crawls this time. Still, there was a litany of “Oh my God; I can’t believe I’m doing this. Oh my God; I can’t believe I’m doing this.”
“Amy, how’s school?”
“It’s fine. Oh my God; I can’t believe I’m doing this.”
“Did you have a nice holiday?”
“Yeah. Oh my God; I can’t believe I’m doing this.”
“Do you have movies picked out to watch after the surgery?”
“No. Oh my God; I can’t believe I’m doing this. Oh my God; I can’t believe I’m doing this.”
Once again, we slipped into the OR and anesthesia was quickly induced.
Amy emerged nicely from anesthesia, as before. I spoke with her mom, and once again she asked if I would care for Amy for her next procedure. I came to really like Amy, and I enjoyed caring for her. When she was to have another surgery, I rehearsed in my mind how our interaction would go. Would I finally break the chant?
The following year, now a newbie teen, Amy received her Valium tab thirty minutes out from arriving at the hospital.
Once again, on the way back to the operating room: “Oh my God; I can’t believe I’m doing this. Oh my God; I can’t believe I’m doing this.”
“Amy, has anything bad ever happened to you under my care?”
“No. Oh my God; I can’t believe I’m doing this.”
“Then why do you keep saying, ‘Oh my God’?”
“I don’t know. Oh my God; I can’t believe I’m doing this. Oh my God; I can’t believe I’m doing this.”
Before her next procedure, Amy, now fourteen, took two tabs of Valium. Once again the litany began: “Oh my God; I can’t believe I’m doing this. Oh my God; I can’t believe I’m doing this.”
“Amy, does chanting ‘Oh my God, I can’t believe I’m doing this,’ make you feel better?”
“I don’t know. Maybe. I guess so. Oh my God; I can’t believe I’m doing this. Oh my God; I can’t believe I’m doing this.”
The final time I cared for Amy, by then sixteen and a junior in high school, the double dose of Valium was taken before leaving home. Now maturing into a woman, her voice had mellowed and was no longer squeaky. Between all of her chants on our trips to the OR, I found Amy to be a really sweet girl.
We pulled out of the sandbox after she kissed her mom, and once we had passed through the double doors into the hallway to the OR, I asked: “Amy, how’s school going? I bet you’re a good student.”
“Yeah, I am. It’s going fine. Oh my God; I can’t believe I’m doing this. Oh my God; I can’t believe I’m doing this.”
I stopped the cart in the middle of the hall, moved from the head of the cart to her side, leaned over the railing, and asked: “Amy, do you have a boyfriend?”
“Yes, I do.”
“What’s his name?”
“John.”
“Amy, has John ever seen this side of you?”
She paused for a moment, then began chuckling. “No. Thank God.” She laughed until she was anesthetized. Finally there was no more “Oh my God; I can’t believe I’m doing this.” In the end, long after I had hoped to, I achieved my goal; I got the smile.
Nearly running with Amy on her cart and down the hall wasn’t fast enough to lessen her anxiety. Pharmacology had failed both Amy and me. Finally, the art of distraction came through. Only after I managed to look at her behavior through another’s eyes, her boyfriend’s, did Amy objectively see herself.
I was proud of having helped her overcome her anxiety. But I never got the chance to watch Amy walk. This is a shortcoming of anesthesiology. Even though I provide care during the most stressful, critical, and intense time, I don’t get to see patients when they return for clinic visits after healing.
DISTRACTION IS NOT WITHOUT its problems. I regret the day I conned one certain teen into revealing the name of her boyfriend.
Poland syndrome is another of those fortunately rare but obnoxious defects that doesn’t alter the length of life, but does alter appearance. Named after the London physician who first described the defect, it consists of one-sided absence of a chest muscle, the pectoralis. In girls, the overlying breast doesn’t develop. This is the one no-doubt-about-it indication for a teenager to receive an implant to balance breast size.
Nikki defined the image of a high school cheerleader. She was pretty and thin, and in her hospital gown there was no hint of any breast malformation. It wasn’t her looks, though, that made her stand out. It was her smiling personality. She was one of those girls it was impossible not to like.
On the trip to the OR, I asked Nikki about a boyfriend, but she refused to surrender his name.
Then I veered onto a path I regret, to this day. It’s a question of integrity, and I compromised my own when I mentioned that the drug she w
as about to receive is known as truth serum.
Nikki said nothing more as we entered the OR. When I was just about to inject the anesthesia induction medication, and with no more talk, Nikki sat up on the table and announced to all not just the name of her boyfriend, but also his phone number. For all I know, the name she gave might have been contrived and the phone number might have reached a you’ve-been-dumped recording. As Nikki emerged from anesthesia, she said nothing—just smiled.
But I’ll always be haunted by the fact that my attempt at pre-anesthesia distraction seemed only to make Nikki more uncomfortable, not more calm.
FEW PROCEDURES INCITE MORE fear and anxiety than those on the penis.
Approaching double-digit age, a boy named Sam required a penile rehab to remove a hood retained from a botched neonatal circumcision. It seemed odd that the family had waited so long before deciding on the procedure. Sam’s age should have prompted me to be more suspicious. Why wait this long? Only the inhibitions of his parents could be the answer.
I entered his room to prepare him for anesthesia and noted his mother sitting to his right, near his head. Before I could say a single word, before I was even near the foot of her son’s bed, she burst into tears that streamed from her eyes and dripped off her cheeks. Her husband, standing against the wall on the opposite side of the boy, dropped his head in an oh-boy-here-we-go manner. She looked straight at me and declared that she was going to accompany her son to the operating room for the induction of anesthesia. “The surgeon said it was OK,” she said.
“No.” Just a single, calmly and firmly spoken word.
“What?”
“No,” I repeated.
“Why not?”
“Because it’s obvious.”
“It’s obvious?”
“Very much so.”
“Really?”
“Yes.”
I didn’t need the grief from a parent’s unchecked emotions following me into the OR. And she didn’t need the extra stress and uncontrolled emotions.
She paused momentarily, considering my words. She didn’t question what was obvious. She turned slightly to Sam, then raised her left arm over his chest and pointed to her husband, while returning her gaze to me.
“Then he’ll go.” She understood her inability to control herself. Her emotions preceded her every word.
I recognized my limits; I wasn’t going to stretch my luck with this mother any further. She had lost the initial and most significant part of her negotiation. She wasn’t going back to the OR with her son, but she also wasn’t about to lose any more. The funny thing is that her son showed no anxiety, quietly focused on the video game he was playing throughout all of this.
A few minutes later, Sam’s father, who had not yet said a single word, put on our bunny suit (a white paper neck-to-toe gown, more like a sack, intended to maintain the sterility of the operating room) and accompanied his son and me through the double doors and into the operating suites.
A few steps inside the double doors, with another fifty feet or more to the OR, the father finally spoke.
“I think I’ve had enough.”
I sized the situation up; it was clear this man did not wish to be here. I looked at his son, who was totally comfortable, then spoke to the father. The problem was that he had said something too soon. I’m quick, but not this quick. Anesthesia could not possibly be induced in the brief amount of time that had elapsed since we left his wife.
“Sir, one piece of advice. Stand here for sixty seconds, then head back to your wife. If you turn around and walk out right now, it’s too quick and she’ll know. The switch for the door is on the wall behind you.”
“Thanks.”
I leaned over Sam and whispered: “Don’t tell your mom.”
“I won’t,” he responded. He was quite happy and remained calm throughout the induction of anesthesia.
All went well, and if his mother suspected her husband’s failure to be in the company of their son through the induction of anesthesia, she didn’t let on.
ANOTHER DAY, ANOTHER ANXIOUS PARENT.
Chase, a two-year-old about to undergo surgery, ran through the halls of our outpatient center playing with the toys, oblivious to his surroundings, and to his imperfect penis. His parents were not oblivious. For this boy, the question wasn’t whether he should be circumcised, but how to fix his original circumcision. By my standards this isn’t a significant surgical procedure, but it is a procedure, nonetheless, that requires anesthesia.
A case such as this offers an example of the most routine of the anesthesia care I provide.
An anesthesia resident prepared everything for the case. She approached me and announced: “Doctor Jay, I saw the patient. He is an otherwise healthy two-year-old that has a skin bridge on the penis. He has no other problems. This will be his first anesthetic, and the mom seemed a little nervous. She says she wants to come back with the boy until he is anesthetized. I told the mom you would talk to her. I didn’t make any commitments.”
“OK,” I said. And I thought: So this is how the day is going to go. A nervous parent present at the induction of anesthesia in a child never makes my job easier. It’s just one more concern for me in the procedure room, one more person to watch, and there is no evidence that parental presence during the induction of anesthesia improves outcomes.
After grabbing a cup of coffee in the lounge, on the way back to the patient intake area I saw Chase happily playing. After reviewing his chart, I talked with his parents. Before approaching the topic of parental presence during anesthesia induction, I discussed every step of the process until he would be anesthetized.
“From the time I walk through this door . . . ,” I said, pointing to the door of the pre-anesthesia room, and I recited my two-minute story.
An incredulous look came over the mother. “That’s all it takes?”
“Yes.”
She stood quietly for a moment, and I was unsure whether I sensed relief or disbelief. She still looked as if she was on the emotional precipice—swaying, ready to tip into meltdown. I tried the best I could to earn her confidence, and I waited for her response.
She turned to her husband, standing quietly beside her. She took a deep breath and then unexpectedly burst out: “Take him. Just take him.” Even though I had not addressed the issue of parental presence at the induction of anesthesia, she had come to a decision. To my mind, a good decision.
I scooped up her little son. But after ten steps or so, just beyond the double doors, I felt remorse. Did she really believe me? Had I given her confidence? Or had I coerced her?
Fifteen minutes after separating Chase from his mother, I went to talk with his parents in the waiting room.
“We’re done. He’s in recovery.”
“You’re kidding!”
“No. He’s really in recovery. We’re done.”
I don’t want to minimize my anesthesia care too much. After all, it does entail risk. There are books many pages long and many pounds heavy that list everything that can go wrong. There are scary case reports in medical journals that document what does go wrong.
A little later, after the parents were reunited with their son, I went to check on them and make sure the boy was comfortable. His mother couldn’t thank me enough; then she announced that she hadn’t slept all night. She had gotten out of bed in the middle of the night, gone to the bathroom, and sat on the toilet and cried for an hour. Her husband, standing in support behind her, arched his eyebrows and nodded, shaking his head up and down, confirming his wife’s story. All I could say in response was: “I wish you had called me. I could have made your experience easier. Have a happy life—and, oh, don’t need me anymore.”
CHAPTER 6
Nothing by Mouth
IT BEGAN IN A DIMLY LIT ROOM WEDGED BETWEEN the postanesthesia care unit and the procedure rooms, a room used as a pre-op holding area for hospitalized patients. The only warmth of this room was a street sign above the door that read “Linda�
��s Place”—white letters on a green background. It was a memorial to the nurse who, for many years, had staffed the room before succumbing to breast cancer far too soon. She used to blush instantly anytime I flashed her a John Belushi grin, a one-raised-eyebrow gaze. I would watch the crimson tide rise up her neck to the top of her head.
In this shadowy space, dwarfed on the adult cart, Michael sat flashing an infectious smile that commanded attention. He was all alone, but unafraid, grinning wide, his teeth fully exposed and made brighter by the darkness of the room. With big brown eyes, bigger and browner than I thought possible, he had the appeal of a teddy bear that you want to give a giant hug. He was just four years old, but beneath his welcoming exterior, a very different, knowing-beyond-his-years boy stopped me in my tracks. Before I was able to say a word, he sized me up, knowing my role as the anesthesiologist—the sleep doctor—and he played his card with panache.
“I had Cap’n Crunch,” he said.
“What did you say?”
Silence.
“When?”
Silence.
To many, the broad, inviting smile, bushy white mustache, and wide British naval captain’s hat and eyebrows of Cap’n Crunch breakfast cereal bring nothing but morning joy (and plenty of sugar). But to me, they call forth the memory of an anesthetic adverse event—a complication—that I will never forget.
Michael’s was my second case of the day. I had worked with his surgeon on the previous case, during which we had discussed Michael’s condition and the plan for his scheduled procedure. He suffered the consequences of a congenital bowel obstruction. There are numerous reasons for blockage of a newborn’s intestines. A segment of bowel may fail to develop (atresia); or a segment may be twisted shut in what is known as a volvulus or a constricting band or an incarcerated (trapped) hernia; or the nerves may fail to migrate fully to the muscle in the colon wall, leaving it unable to contract and propel its contents forward (Hirschsprung disease); or the opening from the rectum may not form correctly, known as an imperforate anus. Michael’s was a complicated case that involved his anus and unfortunately required frequent trips to the OR for exams and dilation. Even at his age, he knew the routine.
Counting Backwards Page 6