His comment about Cap’n Crunch stopped me cold. A stomach filled with cereal and acid—that’s how I interpreted his comment. And it had serious consequences for my anesthesia plan.
FIFTEEN MONTHS AFTER THE first public demonstration of surgery under inhalation gas anesthesia, the first death by anesthesia was reported. In 1848, a fifteen-year-old girl named Hannah Greener went to her doctor’s office for the removal of an ingrown toenail. She died shortly after breathing the anesthesia gas. The exact cause was not determined, but on autopsy, her lungs were found to be congested with blood and fluid. It’s possible the primary cause was heart related—a heart rhythm incompatible with life. It’s also possible that she aspirated stomach contents into her trachea and down into her lungs. Very likely, the event caused laryngospasm, or “dry drowning.”
While consciousness is lost after inhalation of the anesthesia gas, some body reflexes remain intact until the anesthesia level reaches an adequate depth. One such reflex, the laryngeal adductor reflex, causes the vocal cords to close. Before being fully relaxed by the anesthetic, the vocal cords may become irritated and forcefully close. The patient continues to try to breathe against the closed cords, causing injury to the lungs, pulmonary edema, or congestion, and injury or death by asphyxia, lack of oxygen, if not promptly treated.
The discussion of Hannah Greener’s death included the observations that her stomach was full of food, and water and brandy were poured into her mouth in an attempt to revive her. Either might have entered her lungs, or possibly she had not been anesthetized to the point of shutting down her laryngeal adductor reflex and her vocal cords had closed tight. Laryngospasm is an anesthesia complication. Whatever triggered the problem, she suffocated.
Nearly a hundred years after the unfortunate Hannah Greener incident, an obstetrician, Curtis Mendelson, observed that women during delivery are prone to aspirating the stomach contents, in part because of the changes of pregnancy—specifically, the uterus full with the fetus pushing everything in the abdomen upward. The term “Mendelson’s syndrome” eventually yielded to the more descriptive “aspiration pneumonitis.” The goal prior to anesthesia is to allow enough time to ensure that food exits into the intestines and leaves the stomach empty, eliminating the possibility of aspiration pneumonitis.
The separate paths leading to the stomach and the lungs work on the either/or principle. Only one path may be open at a time, and eating and breathing are kept separate through a series of coordinated actions including muscles and reflexes. The vocal cords at the entrance to the trachea snap shut when food or drink enters the mouth. This reflex, the laryngeal adductor reflex, is beyond our active control and prevents anything in the mouth from going down the wrong pipe. To swallow, sphincters made of muscle in the esophagus relax and the contents of the mouth slide down into the stomach.
Gastroesophageal reflux—commonly referred to as GERD (for “gastroesophageal reflux disease”) and also known simply as heartburn—occurs when these sphincters fail and the stomach contents rise in reverse back up the esophagus. Silent aspiration results when the laryngeal adductor reflux fails. Food and drink entering the trachea can block the airway, preventing oxygen in the air from entering the bloodstream. Aspiration also predisposes a person to pneumonia.
Everyone experiences aspiration occasionally by accident. Either excited or impatient, we sometimes fill our mouths with too much food or drink, or too fast, or with a full mouth, and on a startle the contents go down the wrong pipe. Instead of passing down the esophagus into the stomach, the oral contents slide past the vocal cords and into the trachea, the windpipe. The system of protection that keeps the lungs clean and clear has failed. This is aspiration.
Acid is the anesthesiologist’s enemy. The stomach is capable of withstanding the acid it produces as an aid in digestion. But other tissue is not immune to this acid. Herein lies the risk of anesthesia, which relaxes muscles and turns off reflexes. The cinched esophageal sphincters relax, allowing the contents of the stomach to flow to the mouth while the laryngeal adductor reflex no longer guards the entrance to the trachea. To prevent aspiration under anesthesia, the stomach must be empty.
Nil per os. “Nothing by mouth.” The pre-anesthesia routine in decades gone by was to write and order: “NPO after midnight.” With first-scheduled cases in the morning, this worked fine. For afternoon cases, the patient might be left dehydrated. Today, a kinder, gentler sliding timescale is used, depending on the procedure schedule and the type of food or drink. Clear fluids are frequently allowed up to two hours before anesthesia; they don’t fill the stomach with acid and might actually aid in passing its contents out and along the intestines. Fatty foods produce the greatest amount of acid, requiring eight hours to clear acid from the stomach.
TWO OF THE FIRST FOUR ingredients listed on the Cap’n Crunch box are sugar, both white and brown. Given the enticement of an inviting figure on the box, placed at child’s eye level in the supermarket, and the allure of sweetness, what child wouldn’t like Cap’n Crunch? But with Michael preparing for anesthesia, Cap’n Crunch was a potential disaster lying in wait.
I looked into Michael’s eyes. I saw a four-year-old who knew that this comment was enough to cancel his case. But was it true? He needed the medical procedure he was there to undergo. I was not about to cancel it without confirmation.
I always approach the evaluation before anesthesia the same way. First I seek out the reason for needing anesthesia and read the patient’s present history, past history, and past anesthesia records. Then I perform a physical exam and review lab reports and studies. Finally, I develop the anesthesia and pain relief plan. The anesthesia equipment is prepared and arranged the same way every time. I aim to prevent errors, adverse events, and complications—and to have no need to correct them.
I review the entire chart, from front to back of the paper chart, from top to bottom of the electronic chart, every time. The demographic sheet listing the patient’s name, medical record number, birth date, and address occupies the front of the chart. In pediatrics, a parent stands between anesthesiologist and child, and this parent signs the consent. The bottom of the demographic sheet provides equally important information: spouse, next of kin, parent names.
Before I touched Michael’s chart, I scrambled to put things in order. I had heard him and knew what he said, but I remained unconvinced that he was being truthful. Could a child this age knowingly, actively develop such a lie?
A patient not optimized for anesthesia presents increased risk of complications. Food in the stomach at the time of anesthesia poses one such risk. Anesthetizing any patient not optimized for the procedure practically guarantees an encounter with the “retrospectoscope”—the hindsight that displays so clearly later what couldn’t be seen at the time, the “instrument” that raises the question “Why didn’t you . . . ?”
“Iatrogenic”—derived from the Greek iatros (“physician”) and genic (“to be produced by”)—is a word that was developed less than a century ago to indicate something caused by a physician that has adverse effects. Anesthesia can only be iatrogenic. That is, only rarely are my efforts meant to treat or cure a patient’s condition, such as the occasional nerve block for a pain syndrome gone wild. In the vast majority of cases, my intention is that a patient whom I place into a state of unawareness and painless comfort (an induced coma) will emerge from that anesthetic coma in better health by my hands. Some responsibility is borne by the patient and family to follow instructions and adequately prepare for anesthesia. Ultimately, though, the responsibility lies with me.
I looked around the area. No parents and no nurse. Even the transporter who had brought Michael to me was nowhere to be seen. With no one to ask to disprove or confirm Michael’s Cap’n Crunch claim, I turned once again to my little patient.
“Where did you get the Cap’n Crunch from?”
The grin remained frozen on his face. His teeth never parted, and he said nothing.
“When did you have
it?” I prodded again, but still he did not speak. He adopted an impish look. Those brown eyes were no longer as large as they first seemed. He stared right at me, knowing full well the implications of his comment.
The easy way out was to postpone his case. But he needed an exam and would be no better without it, so I proceeded to investigate the Cap’n Crunch claim.
I knew Michael was experienced with anesthesia and surgery. He knew the routine. I suspected he was attempting to trick me into altering my care.
After the demographic sheet and the consent for a procedure, the patient orders follow. Listed clearly was “NPO after midnight.”
“The chart says you were given no food today,” I said. Again, I got no response, as his smile evolved into a smirk.
Slightly unnerved, I decided to check further. I stepped out of the room and phoned the hospital unit that Michael had come from and spoke directly to his nurse.
“No, doctor. He had no cereal. I made sure his breakfast tray was not delivered today.”
I returned to the boy.
“I spoke with your nurse. She just told me you had nothing to eat today.”
He broke his silence with a rapid burst of: “I ate Cap’n Crunch!”
“Where did you get it?”—my voice a bit louder and more imploring than before.
“My mom.” Then the same grin, the same locked lips, and the silence resumed.
“When did your mother give you the cereal? Your mother isn’t here.” I received the silent treatment again.
Back to the phone, back to the nurse from the unit. “No, doctor. His mother wasn’t here today. It has been a couple of days since she has visited.” (A sad, all-too-frequent reality in my practice.) “He didn’t have any food today.”
I looked at the procedure consent and found that it had been obtained by phone. His mother had not been present the previous day.
After challenging the boy one more time, and receiving nothing but silence in return, I returned to the phone. I had reached the limit of the nurse’s patience and had begun to perturb her. “No, doctor,” the word “doctor” emphasized and prolonged. “He has had nothing to eat today.”
I noted in the chart the lengths to which I had gone to verify the cereal story. I considered whether, if he had indeed eaten the cereal, I should wait until his stomach would be cleared. But I didn’t know what time he would have had the cereal. I decided that, at four years of age and with his lack of cooperation, he would not, even if he could, accurately report what time he’d eaten the Cap’n Crunch. An eight-hour wait would deprive him of fluids and possibly cause dehydration. Either he’d eaten the cereal and the case should be canceled, or he hadn’t eaten any and I should proceed.
I believed the nurse. Through due diligence, I concluded there was no Cap’n Crunch. Four false words from a four-year-old were not going to dictate my care.
Off to the operating room we went.
After anesthesia was induced, the “urp” was subtle. Just a tiny flicker of his abdomen. No one except me noticed it. But removing the mask revealed a mouthful of Cap’n Crunch. Yes, he had indeed eaten the cereal.
The next few minutes were nerve-racking. I turned him on his side to prevent anything from entering his airway. I suctioned the cereal out of his mouth. Then, with trepidation, I listened to his lungs with my stethoscope. His breath sounds were clear. He remained pink; his oxygen saturation remained normal. There but for the grace of God go I; he did not aspirate the contents of his stomach, and he emerged none the worse for wear.
Michael later confided that he had sneak-eaten his roommate’s breakfast. I resisted the temptation to call the floor nurse.
THE WEIGHT OF RESPONSIBILITY, or maybe the sense of guilt, from this almost adverse event, this near complication, hasn’t diminished with time. The colors of the room, the green on the street sign, the time on the clock on the wall, the words exchanged remain just as crisp within my memory as the day it all took place. The drive for perfection persists, and that may be the most damning part of this case. No matter how I reevaluate the facts, my decisions never change. Given an identical situation today, my care would be the same.
Danger lurks.
I do not mean to incite fear of anesthesia. This four-year-old might have died because of my care, and if he had, he would have been the first and only patient without beforehand identifiable risk of death to do so in my career. It is more probable to be struck by lightning than to die while under anesthesia. The risk of dying from anesthesia is less than one in a hundred thousand cases. It’s about the same risk as dying as a result of skydiving, participating in a triathlon, or riding a bike. Anesthesia is very safe. But anesthesiologists can never, ever let their guard down.
A patient’s “physical status” is a numerical assessment by the anesthesiologist of the patient’s overall health. A PS1 patient is healthy. A PS2 has a compensated health problem not impacting everyday life—high blood pressure controlled with medications, for example. Eighteen holes of golf presents no problem. A PS3 suffers from a life-altering condition, such as heart disease that makes it difficult to function normally—for instance, to walk up a flight of stairs. PS4 and PS5 patients are at risk of dying or are expected to die. Anesthesia risk rises as the PS number does. It’s mildly curious to me that no patient has ever asked for my PS assessment.
In my career of thirty thousand anesthesia cases, give or take a few, during my care PS1 and PS2 patients have come in healthy and gone out healthy—no exceptions. I have also had patients living between the proverbial rock and a hard place, patients for whom the only chance at continuing life was the procedure room. Not all have survived. I carry, and always will carry, the memory of every one of those patients.
The simple fact is that a healthy, nourished, hydrated patient presents the best chance for an optimal outcome. No solid foods for eight hours before anesthesia. Avoid fatty foods. Only clear fluids, fluids you can see through that don’t contain fat (in other words, no soups and broths) until two hours before the scheduled anesthesia. Control what can be controlled: blood pressure (hypertension), blood glucose (diabetes), and airway disease (asthma and chronic obstructive pulmonary disease, more commonly referred to as “COPD”); if quitting smoking isn’t a possibility, at least stop for several days. Put the data in your favor.
Although death during anesthesia is rare, adverse events do arise. Postanesthesia nausea and vomiting is the most likely issue. Placing a number on the incidence of nausea and vomiting after anesthesia is difficult because nausea is a subjective complaint, and even vomiting is not so easy to evaluate. Spitting out oral secretions is not vomiting. Nausea and vomiting are also procedure specific. Eye surgery is notorious for post-procedure nausea and vomiting (PONV), with reported rates of up to seventy-five percent. The often-quoted incidence of PONV after general anesthesia is thirty percent. In my experience, fifteen percent is more accurate. I surveyed my cases over a several-month period and discovered a six percent incidence of PONV in the first twenty-four hours after general anesthesia.
Damage to teeth is another of the more common complaints. Again, the numbers vary widely, from less than one percent up to six percent.
These two issues are what I term nuisance problems. I don’t mean to minimize their impact, but these issues don’t risk life. Of the more common and real adverse anesthesia events, respiratory complications occur at a rate of about one to two percent. Respiratory complications range from less-than-expected oxygen levels (low pulse oximeter readings) to pneumonias and aspiration pneumonitis.
ADVERSE EVENTS BEYOND THOSE of a respiratory nature fall into the “rare” category.
Early on in medical school, a lecturing doctor introduced a woman to my neurosciences class and asked her to flap like a bird. By the fifth flap she could hardly raise her arms. We were witnessing the effects of a disease named myasthenia gravis (from the Latin for “muscle weakness” and “grave” or “heavy”). In this condition, the receptor on a muscle that rec
eives the chemical transmitter released at a nerve ending as an instruction prompting a muscle contraction doesn’t work. The condition is very rare. Even in my high-risk practice, I see only about one case of it each year.
The anesthesia equivalent to myasthenia gravis is frequently termed an “allergy,” but it is not. A reaction to certain anesthesia drugs leads the muscles of the body to run amok, resulting in high fever, high heart rate, and high carbon dioxide levels. If unchecked, it leads to death. Malignant hyperthermia (MH) is a genetic variant that predisposes certain patients to this metabolism-gone-awry reaction, but the condition is extremely uncommon. An anesthesiologist with a busy practice of both adults and children will encounter one case of MH every thirty-seven years. Although as similar in incidence to myasthenia gravis, every anesthesiologist is required to know all there is to know about MH, and essentially no one should die from it.
The potential risks of anesthesia—both common and rare—require anesthesiologists to remain vigilant and to maintain a wide scope of knowledge to ensure optimal outcomes. Every box of Cap’n Crunch serves as a reminder that anesthesia complications lurk in the shadows.
CHAPTER 7
Heartbeats
BEFORE I ENTERED MEDICAL SCHOOL, I NEVER dreamed that the sight of the human heart, exposed and beating in front of my eyes, would move me so deeply. The first time I saw it was a religious experience. The brain is the most complex organ, but its energy isn’t visible; there is no action, no movement, and thoughts can’t be seen. The heart is the most inspirational organ to observe, to touch, to feel. Nothing stirs my medical emotion more than watching the heart deep in the chest, lurching with every beat. Unlike any other organ, it’s always in motion, never resting. Its beat defines life.
The size of a fist, the heart, with its maroon surface, obscures the red in a chamber lying beneath. With patches of pale-yellow fat adding to its shiny surface, its many curves and rhythmic movement reflect the light of surgery in a continuously moving array. In the heart’s vault of ivory-colored walls, in a shallow lubricating bath, its every movement creates a sloshing sound, “la-lup,” a couplet unmistakable and instantly identifiable.
Counting Backwards Page 7