Several notes by physicians and social workers indicated that Bandul had failed to take an antirejection medication for nine days prior to coming to the ER. This anesthesia record was not railroad tracks. There were a few bumps. His blood pressure varied—not severely, but noticeably—and Bandul was placed on medications to support his transplanted heart’s function.
My interactions with Bandul were always pleasant and polite. When I transferred him from the cardiac cath lab to his room, his parents—as devoted as could be—sat on a couch beyond Bandul’s bed and leaned forward in silent anticipation, his father with his hands clasped together between his knees, his mother with her hands folded in her lap. Their eyes grew large and forlorn, as if they knew the extent of Bandul’s illness, praying that I held the answer, the cure.
In addition to having me as the pediatric cardiac anesthesiologist, Bandul received care from the ER physician, the pediatric transplant cardiologist, the pediatric interventional cardiologist, the pediatric interventional radiologist, the pediatric pathologist, the congenital cardiac surgeon, and the pediatric cardiac intensivist (critical-care physician). And then there are the nurses and all the other technicians necessary to complete this team of astounding expertise. But despite the mastery of the team, our reach beyond the walls of our medical center is not all-encompassing.
Teenage brains lag behind their bodies in development. A kid may look like a sleek and buffed sports car on the outside, while what’s under the hood isn’t yet perfected. Teens have pedal-to-the-metal accelerators, but they lack competent brakes. Subtle changes to the brain continue into the twenties, gradually containing the twitchy impulse control—or lack thereof—and the emotional volatility of the teen years.
The law expanding Medicaid coverage and providing care to all children, no questions asked, resulted in an unintended consequence. The benefit wasn’t never-ending. The gratuity needed a sunset. While physicians as a whole, and especially pediatric specialists, focus on a patient’s life for decades ahead, no end of care exists. The writers of the law failed to recognize the needs of a patient like Bandul eight years after his transplant.
The politicians decided that their generosity ended when kids were no longer kids. They defined that moment as the last day of the month of a child’s nineteenth birthday. So, Bandul was no longer provided his medications. Bandul worked with his father at odd jobs as they became available, and he dreamed of attending college and entering the medical field. The school he inquired about was a drive away. On impulse, he chose savings over purchasing the transplant rejection–preventing medication that now cost him twenty-five dollars per day. Just the first few moments of Bandul’s prolonged intensive care stay consumed the two hundred dollars he had saved, as the hospital room charges alone came to hundreds of thousands of dollars. The total of the charges accumulated during his stay, including tests, therapy, and procedures, would have paid for years of Bandul’s preventive medications.
Bandul died on hospital day fifty-seven.
I play no role in the decisions made beyond my involvement in a case. My role and my goal are simply to provide the most skilled anesthesiology care possible. And I don’t function alone; I am a proud member of one of the elite teams in the world of medicine. But the success of the team, and the health of the child heart recipient, often lie outside the team’s grasp.
CHAPTER 8
A Most Unusual Patient
DURING MY SURGICAL TRAINING, A VERY GIFTED surgeon offered a surprising piece of advice: “Treat every patient like dirt. Then every patient will be treated exactly the same.” His intention was clear: treat everyone as equal so that a patient’s status doesn’t alter the process. My take was to treat everyone the same, but like royalty.
I always remind myself that there are no VIP patients. But some patients are more unusual than others.
After a three-day holiday weekend, I walked into the hospital and approached the surgical control desk. When I’d left the previous Friday, I hadn’t yet been assigned any cases for the following Tuesday. Over a weekend—especially a long weekend—schedules change. There is plenty of time for patients to be admitted, for surgical illness to arise, for injuries to occur.
The fellow in pediatric surgery (fully trained in general surgery, now training in his subspecialty) stopped me short of reaching the desk.
“You free?”
“I don’t think I’m on the schedule. Why?”
“Come with me. I need a hand.”
Retracing my path down the hallway and out of the hospital, we unexpectedly turned into the research building. This building housed the facilities for virtually every type of research, from running chemical reactions in test tubes, to growing cells, to the rare larger animal experiment. I didn’t think the surgical fellow was asking for help on a chemistry or microscopic cell–based project. Although trained as a chemist, I hadn’t practiced chemistry for many years, and I had never attempted cell-based research. My imagination began to run.
Health care research is a necessary minefield. It’s a bit of a bet: asking the right question, developing a plausible solution, spending time, energy, and money collecting data—all in the hope of determining a definite answer. A long road to potentially improved care and outcome lies distantly ahead. No alternative to research conducted on the living yet exists, and we probably won’t ever be able to resolve all the ethical issues involved in such research.
Research studies on humans are often attached to required care. Patients suffering an illness are offered alternative experimental therapies, trial drugs, or untested techniques in addition to the accepted drugs and procedures used to treat their condition. For example, a patient undergoing knee replacement surgery might be asked to take part in a study on postoperative pain relief, but the surgery will take place whether or not the patient participates in the research protocol. Human studies have opt-out clauses. An unsatisfied patient, or one who has a change of heart, can voluntarily end participation in any study at any time.
Animal studies are a very different story. Healthy animals tend to be used in research, and it’s hard to do no harm when nothing is wrong to begin with. The onus rests on the researcher to demonstrate that the research is warranted, that an animal model is a necessity, and that the animal will not be hurt or suffer throughout the study. Animals are unable to voice their discomfort or invoke an opt-out clause. As a result, the demands on researchers to ensure the animals’ well-being tend to be more stringent than for human studies, and there is zero tolerance regarding any potential for the animal subjects to experience pain.
I’ve consulted on animal care protocols, ensuring that no breaks in the standard of care exist, that comfort is complete. But just as animal anesthetists are not versed in human anesthesia, I am not versed in animal anesthesia. When I wrote and submitted a research proposal for an animal study that would investigate how cardiopulmonary bypass affects lung function, it was initially rejected for not meeting animal anesthesia standards as determined by veterinarians and the facility’s institutional review board, even though my proposed anesthesia exceeded the standard human requirements accepted by anesthesiologists.
ON THE WALK TO the research center that Tuesday morning, as my mind wandered over the possibilities, I was excited to think that my expertise might be needed to address a research issue.
Entering the animal procedure room, I froze. My expertise hadn’t been requested for a research dilemma. In the center of the room, on an obsolete human OR table repurposed for research, a gorilla lay motionless. She was named Tabibu. Even as sick as she was, Tabibu was stunningly beautiful. Dwarfed by the adult-sized OR table, at less than two years old, she was about three feet tall and perhaps thirty pounds, with intensely dark-brown fur and skin a deep midnight black. I stepped to the bed, and her two handlers shuffled away from her, perhaps accepting the gray of my lab coat as authority. Tabibu’s open eyes were the color of dark-roasted coffee, but they were dull and didn’t reflect my image.
I melted. Before I could kick into detached physician mode, I needed to conquer my empathy—that hug-the-puppy desire. I listened as the surgical fellow and one of the animal handlers, who turned out to be the zoo vet, provided me with the details of Tabibu’s condition.
Three days earlier, my anesthesiologist colleague on call for that weekend’s emergencies, Andy Roth, had received a call from our pediatric surgeon, who in turn had received a call from the zoo. Late the week before, Tabibu had become severely ill with an acute abdomen. In humans, an acute abdomen is severe—an incapacitating belly pain that develops over a short period of time. The patient is bent over in agony, unable to stand straight. Lying flat on a bed, the patient avoids all movement because moving causes the abdominal contents to shift, triggering a pain response.
The zookeepers had noticed that Tabibu had stopped eating, become lethargic, and retreated from all social contact. Concerned, on Saturday morning Tabibu’s keeper had called the zoo vet. In comparison to human medical specialties, the zoo vet is the family doc caring for hundreds of species—from snakes to birds, pygmy shrews to rhinoceroses. The zoo vet’s net of knowledge is cast wide, but not necessarily deep.
This vet understood the severity of Tabibu’s illness and realized that the situation exceeded her ability. She contacted our pediatric surgeon because a juvenile great ape physiologically and anatomically is not too dissimilar from a small child, and a gorilla’s genetic profile is at most a couple percentage points different from that of a human. The surgeon recommended transferring Tabibu to our research facility for evaluation. Our surgeon confirmed the diagnosis of acute abdomen. Tabibu needed surgery. Her abdomen might contain an infection, an obstruction of the intestines, or a disruption of blood flow (ischemia) to an organ.
Andy was asked to provide anesthesia for an exploratory laparotomy. In this procedure, the surgeon opens the patient’s abdomen, exposing the organs to determine what’s wrong. This is a major procedure in elective situations, and in emergencies it is fraught with risk, both from the anesthesia and from the surgery.
Once Andy Roth had safely anesthetized Tabibu, surgery revealed an infection that was eating away part of the wall of her colon. The diseased section was removed, and she emerged from anesthesia as hoped.
A human patient who undergoes an abdominal surgery will not be released from the hospital until clearly able to eat and drink, and after having a bowel movement. Concerned for the safety of both Tabibu and her keepers, however, the vet insisted that Tabibu return immediately to the zoo. But the vet had not taken into account the impact of the surgery on the patient. Back at the zoo, Tabibu’s problem wasn’t pain, which could be—and was—controlled by her keepers, but the fact that surgery on the bowels results in the condition of ileus: her bowels stop working. Muscle in the walls of the intestines stops squishing and propelling the contents downstream. Fluids and nutrients were not being absorbed.
A chain reaction results from not eating or drinking, and dehydration sets in if intravenous fluids are not supplied. The heart rate rises in an attempt to maintain adequate blood flow, but eventually the blood volume shrinks beyond the point of compensation by the heart and the blood pressure falls. This is what doctors refer to as shock, and it can be fatal if not promptly reversed.
During my care, I held Tabibu’s hand and rubbed her head. I grasped her arm; it seemed thinner than a child’s as my fingers encircled it. Her fur felt stiff and wiry and her skin thick. The only movement she was able to make was to roll her upper lip out. Her inner lip was dry—another sign of dehydration. She didn’t withdraw or resist my advance in any way, a not-so-subtle indicator of how ill she was. Her breathing was what a physician would describe as agonal: rapid and shallow, with an occasional sigh and pause.
Tabibu’s heartbeat was fast, but her EKG appeared normal, meaning that her heart was beating with a regular rhythm. That was a good sign. However, it was clear to me—from her heart rate and breathing—that Tabibu was in shock and was approaching cardiac arrest.
THE DOSE OF THE ANESTHESIA gas is measured as a percentage of the overall inhaled gases (as mixed with air and oxygen). The minimum alveolar concentration (MAC) is the percentage of gas inhaled that prevents fifty percent of patients from responding to a painful stimulus. Whether it’s a mouse, red-tailed hawk, monitor lizard, elephant, or human, regardless of species or size, the percentage of inhaled gas necessary to achieve the state of chemical coma is remarkably similar. Greater change exists with advancing age than between species: once you hit maturity, the older you are, the less gas you need.
The same cannot be said for the anesthesia drugs administered by injection. Differences in species alter the IV (intravenous) or IM (intramuscular) dose of the drugs necessary to provide anesthesia. More to the point, the required amount of drug increases as the level of oxygen consumed increases. Small species tend to consume oxygen in amounts that are magnitudes higher per pound or kilogram than the amounts that larger species consume and, as a result, anesthetizing small species requires larger doses of drug. The dose per pound of an anesthesia drug injected into a human might kill an elephant but leave a mouse unfazed and staring at you, wondering what just happened.
Providing anesthesia for Tabibu was, intriguingly, not that different from caring for any eighteen-month-old child. I prepared my space around Tabibu’s head. I checked to ensure that I had the ability to provide oxygen and to breathe for Tabibu as necessary. I checked my airway equipment—the laryngoscope and endotracheal tube of appropriate size—and prepared my emergency drugs, including epinephrine if her heart needed a kick.
By my assessment of her breathing, Tabibu needed to be intubated, and quickly. She might stop breathing—apnea—at any moment. I chose to use an injectable anesthetic, ketamine, a drug that doesn’t cause a change in breathing or in blood pressure, either of which might be fatal for Tabibu. She barely flinched before succumbing to its actions. When her eyes bounced from side to side (nystagmus, a sign that the drug was working), and with her breathing in oxygen-enriched air unchanged, I moved to her side to search for a vein where I could place an IV to replenish the fluid volume. There was no hope of seeing the hue of blue that would indicate a vein beneath her thick, brown skin, but on her right forearm, I noticed the slightest bulge.
I reached for an IV catheter consisting of a hollow plastic catheter sheathed over a very sharp stainless-steel needle an inch or more in length. The needle enters the vein, and the catheter slides off the needle, coming to rest inside the vein. IV catheters come in a variety of diameters (called “gauges”) designated by the color of the hub of the catheter. The larger the diameter, the more quickly IV fluid flows in. I grabbed one with a blue hub (a twenty-two-gauge catheter) and envisioned myself placing that needle into the vein, sliding the catheter off, and feeling it come to rest within the vein lumen.
Frankly, I was being a wuss. Tabibu needed fluid, and lots of it, and a twenty-two-gauge catheter was too narrow to rush intravenous fluids into her body. Considering the amount of fluid she needed, a larger, twenty-gauge catheter (pink by color) would have made me happier, but I lacked the confidence to accurately place it. With only one vein visible, I had one shot, and failing was not an option. Once more invoking John Hughes with “Our Lady of Victory, pray for us,” I pierced her skin, which was much tougher than I had anticipated; the needle bent slightly. I like to think that I’m pretty damn good at inserting needles into tough spots, but this was one of the most difficult veins I ever cannulated. For the umpteenth time in my life, I might have once again proved that no amount of skill can replace dumb luck.
I managed to get the needle into the vein, slid the catheter off, and started infusing IV fluids as fast as the narrow diameter allowed. I moved back to Tabibu’s head and, with my left hand, held the mask I’d chosen as the likely best fit to her face, while with my right hand I injected a paralyzing drug into the IV to allow me to open her mouth and see the voice box that my breathing tube would pass thro
ugh. I needed to breathe for Tabibu by mask until the drug took effect. Her jutting chin and wide nose made applying a breathing mask more challenging. I knew the drug was working when I could open her mouth without resistance. I placed the endotracheal tube through her mouth and into her trachea and secured it with tape to her lips. Turning on the ventilator, I watched Tabibu’s chest rise and fall with every delivered breath, adjusting the settings until I was satisfied with the volume and number of breaths. The anesthesia gas was added cautiously.
Because she had not been eating or drinking, Tabibu’s blood volume had dropped dangerously low, resulting in fluctuating blood sugar and oxygen levels and altering her electrolytes (the salts in the blood). In response to these changes, her breathing quickened and her heart pumped harder. We sought to reverse all these abnormalities by repeatedly measuring as many variables as possible and promptly making corrections until Tabibu was once again able to fend for herself.
With Tabibu motionless from my anesthesia, the surgeons gained the ability to expose a vein in her neck and place a bigger-diameter catheter inside it. Now we could easily sample her blood, monitor the results, and make adjustments to return her blood volume, as well as the levels of the various salts contained in the blood, to within normal limits. After every clinical adjustment, a new blood sample was obtained and the surgical fellow and I reviewed the results. While the numbers steadily improved throughout the day, Tabibu was by no means out of the woods. Her condition could still change for the worse, and rapidly so.
When I checked on Tabibu late in the afternoon, her numbers were continuing to improve, so I drove home.
THAT EVENING, SITTING WITH my family at dinner, I announced to my eleven-year-old, animal-loving daughter Annie that there was something I needed to do and I would enjoy her company. Annie dreamed of becoming an animal nurse, and this was a once-in-a-lifetime opportunity. As we sped down the entrance ramp to the highway pointed toward the city, Annie looked at me and guessed we were driving to the hospital.
Counting Backwards Page 9