“Yes.” I didn’t elaborate, and she took a stab at the reason.
“We’re going to see a patient.”
“Yes,” I said.
“Who is it?”
“You’ll see soon enough.”
After parking the car, we walked up the hospital drive. But instead of turning right to the hospital lobby, we turned left toward the research center. Now Annie was very confused. She hadn’t entered this area of the medical center before. In the hospital, displays oriented to children enliven the space. The research center lobby, by contrast, is a vestibule; the hallways are narrow and the walls are barren. The colors in the research center are neutral, and the only decorations are posters demonstrating research projects. The ceiling lighting fixtures, spaced wide apart, cast areas of brightness alternating with dark. The doors to the rooms are solid, without a window to give a glimpse of what’s inside. This was not the welcoming place Annie had experienced in her previous visits to the hospital.
Annie followed as I opened the aluminum-cased glass doors that separate the floor into different departments. We climbed a narrow staircase up one floor. I opened the final door and stood back to let her enter first.
Annie stood motionless and wide-eyed—the same momentary paralysis that I had experienced earlier in the day. She broke free and ran to the side of the table. Tabibu was still not moving, except for a tiny twitch of her upper lip. I reached out and, with the outside of my extended index finger, rubbed the inside of Tabibu’s exposed lip. She seemed to look at me, and she kept her lip raised. I believe she found comfort in that small gesture.
Annie asked if she could touch Tabibu. “Yes, you can.”
Annie held Tabibu’s head and, with her index finger, replaced mine and gently stroked Tabibu’s lip.
My Annie is comforting a gorilla, I thought.
Blessed with a wonderful career, I reflected on how much more I might possibly experience. Could it get better? Every day holds the potential for a surprise, but this day delivered one. I crossed a divide between caring for humans and caring for animals. I’m not sure which was more special—watching Tabibu make even the slightest improvement or seeing the emotions on the faces of the people nearby. Most amazing to me, however, was watching Annie hold Tabibu and comfort this magnificent animal. It left me in awe. What joy.
THE NEXT MORNING, I WAS UP and out of the house extra early to allow myself time to evaluate Tabibu before beginning my scheduled cases. The results of Tabibu’s blood draws indicated that we were reversing the dehydration, though the improvement was subtle. I met with the surgical fellow outside the door to Tabibu’s room, and we agreed we were doing pretty damn well. But there was a long way to go.
The zoo vet approached us. “We’ll have to make a decision soon about when to end care. The cost of keeping her alive will be prohibitive.” Standing nearby was the zoo director, who, as I recall, remained silent.
The surgical fellow’s response and mine came in stereo. The words flying from our mouths, the tone, and even the tempo were nearly identical—as if we had rehearsed our response: “I’m sorry, but Tabibu is under our care now. She’s our patient, and we’re making all decisions. Calling it a day is not an option.”
“But we can’t afford it.”
“That’s not your problem. It’s ours.”
I think I saw a relief-filled smile from the vet. Tabibu’s welfare had become our responsibility, not hers.
There would be no charge for our professional services. Volunteers provided all other needed care, including nursing and respiratory therapy, and more than enough people offered their time to watch Tabibu twenty-four hours a day. The hospital administration, like the physicians, had chosen not to charge for the space or equipment for Tabibu’s care, save for a tank of oxygen. They also chose not to publicize our unusual patient; understandably, I don’t think they wanted to respond to the possible issue of giving free care to animals but not to needy and unfortunate humans, even though patients were never turned away for their inability to pay.
Annie returned with me to the hospital for the next two evenings and rubbed Tabibu’s lip, which gave a little more response on each visit. Several days passed before the turnaround occurred. When Tabibu got well, it was like flipping a light switch. On Friday afternoon, four days after entering our care, Tabibu awoke. I removed the breathing tube from her mouth, and she sat up. Tabibu remained calm, demonstrating no agitation or aggressive behavior. I think she was still dazed from all that had happened to her and probably from the drugs she’d received. She was moved off the table and placed, uncaged, in an empty room-turned-pen. All the furnishings had been removed, and nothing hard or large enough to hurt if swung or flung remained. Blankets and pillows served for comfort, and she was able to move about with no chance of injury. Tabibu began to drink and to try some of her food.
The following morning, I received a call letting me know that Tabibu, growing increasingly active, had resumed her life in the great-ape house of the zoo.
A month later, the zoo graciously hosted a picnic for all those involved in Tabibu’s care after closing one evening. My whole family accompanied me. It was a memorable evening. The polar-bear keepers stayed late to feed the animals, to our delight. Strolling the empty zoo was a treat. It seemed magical to wander the paths as night set in. The lights of the city provided an urban backdrop to the animals and exhibits, and the stars provided a show above.
I slipped behind the scenes, through the zoo’s version of the automatic double doors, to the inner workings of the great-ape house. With only Tabibu’s keeper escorting me, we walked behind the enclosure into the “Authorized Only” area that the keepers use for feeding and cleaning the gorillas. For one last time, I got close to Tabibu—this time with her sitting just beyond a pane of glass and preoccupied by something in her hands.
She was even more beautiful in her good health. There was no hint that she understood who I was or what role I’d played in her recovery. There was no hint that she recalled who had rubbed her lip for comfort while the ventilator breathed for her, or that she even noticed me. Sure, Tabibu’s lack of recognition made me a bit sad. But anesthesiologists are commonly behind-the-scenes physicians, forgotten after providing care. And watching her in her home, healthy and seemingly happy, provided the cure for my sense of a lost friend. Every time I observe an animal separated by a pane of glass, memories of Tabibu are reborn.
CHAPTER 9
Errors Everlasting
SHE THOUGHT I SAVED HER DAUGHTER’S LIFE. I thought I screwed up. Years after caring for her child, I’m still unable to satisfactorily resolve this conundrum.
Toward the end of the day, deep in the OR suites, I was about to induce anesthesia to repair a broken arm when my pager vibrated. Pagers are both the bane of my existence and a treasure. I’m always reachable; that’s the good. I’m always reachable; that’s the bad. In medicine, I suppose there is no such thing as a good time to receive a page alerting me that somebody needs my attention. But there certainly are bad times. The callback number for this page was from our anesthesia prescreening office. I assumed that a nurse had a question concerning an upcoming case that she felt more comfortable having an anesthesiologist address.
I can’t remember whether I was the on-call person assigned to field these types of questions that day, or if I got the call because the nurse just knew I was around. Or maybe my partner assigned to this task didn’t respond. In any case, I was preoccupied with the patient in front of me, so I returned the pager to its home on the waistband of my scrubs and promptly forgot about it. Sometime later, maybe half an hour, I remembered the page and, feeling guilty, was compelled to answer in person. I found the nurse, apologized, and asked her what was up.
“There’s an eleven-month-old scheduled for ear tubes and a hernia repair. The last time she was scheduled, she had pneumonia and was canceled.”
“Healthy now?”
“According to Mom.”
“Do we have a
note from the pediatrician?”
“Yes. He thinks everything’s fine.”
“OK. Schedule her. Tell Mom I reserve the right to change my mind once we examine her. And I’ll do the case myself.” That’s my standard response when presented with a case tagged with an issue. It’s easier to provide the care myself and not cuff my colleagues with my decisions.
I gave the final answer and accepted the responsibility. The pediatrician was likely accurate—I wasn’t second-guessing him—but sometimes the situation changes and the patient presenting for my care is not in the same condition as when last seen by the primary care physician. Kids are a host waiting for a virus, and the night is always ripe for attack. Evening ends fine and healthy. Morning carries a new illness and concern.
Several weeks later, my mind having erased all memory of that page, a now one-year-old girl named Jill arrived for ear tubes and a hernia repair. Jill’s mom held her in her arms in bed space 9, and I didn’t connect all the dots. I failed to immediately recognize that she was the previous pneumonia and phone call infant patient.
Then the case and Jill veered from the straight and narrow into one giant philosophical mud puddle.
MY ANESTHESIA RESIDENT PREPARED Jill for the case. When asked, he responded: “Her lungs are clear.” I spoke with Jill’s mom, who voiced no concerns. I attributed her nervousness as that of a typical parent surrendering a baby to an unknown entity, me.
As I reviewed Jill’s medical record, I might have remembered the discussion with the screening nurse. A physical exam by the pediatrician followed her and stated that all was good to go. I questioned my resident regarding this infant’s physical exam, and he said there were no issues. I talked with Mom, who had nothing to add. I believe I heard his mother say: “Take good care of her.”
OR 11, a room reserved primarily for urology and ENT (ear, nose, and throat) cases, was the perfect room for this combined case. It’s not just small; it’s tiny. For this combination of procedures, besides the microscope for the ear tubes, the equipment was basic. The room fit. With Jill sitting on the OR table, my resident stood at Jill’s head in the anesthesia nest while I stood at Jill’s left arm, applying the monitors as I had many thousands of times before. I placed the puppy dog stickies, the gummy EKG pads decorated with mini dog cartoons, on Jill’s chest, then wrapped the glow Band-Aid (the pulse oximeter) around her left thumb. My resident placed the mask over Jill’s face and began to induce anesthesia by gas.
Jill remained sitting up while her anesthesia was induced; then we laid her down. I moved into the nest while my resident went around the OR table to start an IV. With the IV in place, I removed the mask from
Jill’s face momentarily to allow the resident to return to his place at Jill’s head. The pulse oximeter reading dropped—not dangerously, but any drop was not right. The level of oxygen in Jill’s blood was lower than it should be. The mask was off only a few seconds, and this drop came awfully quick. Too quick. I noted it as the case moved to its next stage.
Normally, placing ear tubes is done with not much more anesthesia intervention than holding the mask to the patient’s face and allowing the patient to breathe without assistance. But since there was also a hernia repair to be done, I decided to use a plastic airway device, an LMA (laryngeal mask airway) slipped into the back of Jill’s mouth. In a case such as this, the LMA eliminates the need for my hand to hold the face mask. When the mask was removed from Jill to place the LMA, the tone on the beeps of the pulse oximeter dropped again, indicating lower-than-anticipated oxygen levels. This was real, not an artifact.
Of the monitors I use, the pulse oximeter is the attention-grabbing commander. The glow Band-Aid is a single-use light and receptor that wraps around a fingertip and is held in place with an adhesive elastic strip. The reusable version for adults is a larger finger clip. The patient’s finger glows from a painless red light source that shoots through the skin and tissue and is received by a photoreceptor on the opposite side. The red light is actually two separate lights, one red and the other infrared.
Hemoglobin, the oxygen-carrying component of blood, absorbs the light differently, depending on whether it is loaded with oxygen or not. The hemoglobin carrying oxygen absorbs the infrared wavelength, while the naked hemoglobin absorbs the red light. The monitor provides a number based on the percentage of hemoglobin that is oxygen rich. Healthy people have pulse oximeter values in the midnineties or higher. One hundred percent—hemoglobin that is fully loaded with oxygen—comforts me the most. The monitor also displays a signal strength tracing and sounds a tone with a pitch that decreases as the oxygen saturation decreases.
The tone is the attention grabber. Even a single percentage point drop in saturation results in a perceptible change in pitch that twists the necks and turns the heads of everybody in hearing range toward the monitor.
The peaks and troughs on the monitor don’t necessarily correlate to the patient’s condition; many external variables contribute. The readings on the monitor can even be deceiving. Far too often, when the readings waver, all eyes home in on the monitor screen. I’ve resorted to placing a towel over the screen to stop residents from watching it instead of the patient. Sometimes I sermonize. “What do you call a person who stares at the monitor all day? A statistician. What do you call a person who stares at the patient? A clinician. Which would you rather be? You don’t need to go to medical school to stare at a monitor.”
It is true that the pulse oximeter sees much better than the human eye. I’ve observed skin color in patients under anesthesia for decades. When I test myself against the pulse oximeter, I’m unable to determine a dropping oxygen saturation until the pulse oximeter reads eighty-seven percent. But it would be wrong to think that this monitor drastically improved health care outcomes. To date, the pulse oximeter has not been proved to be effective in bettering outcome.
Still, the pulse oximeter provided the impetus for me to identify Jill’s problem and to make a diagnosis that was potentially lifesaving.
Hearing the tone of the beeps on the pulse oximeter drop, I suddenly realized that Jill was the infant with a previous pneumonia that I had been consulted about. I was left only to ask myself how I’d been so damn oblivious.
HEALTHY INFANTS DON’T JUST contract pneumonia. I can’t count the number of times I’ve taught residents-in-training that wheezing and pneumonia in infants are signs of a greater underlying problem. With my superspecialization of anesthesia for congenital cardiac disease, heart defects are the most common cause I see. Jill might have an undiagnosed heart defect. Failing to pursue the pneumonia issue at the initial page was my first mistake. I had blindly trusted the pediatrician and his assessment. Not listening to Jill’s lungs myself before the OR was my second error. Trust but verify.
I reached for my stethoscope, knowing that my exam would most likely reveal abnormal lung sounds. I anticipated hearing the little popping sounds that indicate air is entering blocked lung alveoli, the little terminal sacs that exchange oxygen in the air with the blood. This is the sound made when the lungs have too much blood flow from a maldeveloped heart and the sacs are filled with extra fluid. The sound, termed “rales,” is made from the air sacs popping open with the rush of air. Maybe I would hear wheezing, the sound that air leaving the lungs makes when the airways become narrowed by muscle in the walls tightening. Wheezing would imply asthma.
The ENT surgeon finished placing the ear tubes and moved off to the side to allow me access to tiny Jill’s chest. Her breath sounds weren’t as I expected. I didn’t hear abnormal breath sounds; I heard no breath sounds throughout the left lung field. Something was blocking air from entering her left lung or was deadening the sounds from being transmitted through the chest wall into my stethoscope. I no longer suspected undiagnosed heart disease; that would affect both lungs. This was all about Jill’s left lung.
I told the staff in the room that I wanted an X-ray in recovery. The surgeons, both the ENT and urology attendings, looked a
t me.
“We’ve got something here,” I announced. The rest of the room just stared. Normally, the oxygen content of the gases I provide the patient is twice that of room air. In the oxygen-enriched gas that Jill breathed, her pulse oximeter reading throughout the procedure remained normal, her hemoglobin saturated. Now, in the middle of the surgery, canceling the procedure already under way seemed counterproductive. The only choice was to move ahead.
Jill’s hernia wasn’t repaired earlier because the pediatrician had heard some wheezing during the presurgical physical exam. The goal was to optimize Jill’s health. The case was postponed.
The remainder of the case progressed well, but one more test at the end of the hernia repair surgery reconfirmed what I already knew: Jill’s lungs were not filling her blood with the correct amount of oxygen.
In recovery, the chest X-ray I ordered was taken. Before the results were ready, Jill’s mother came to be with her in recovery. I spoke with her.
“I ordered a chest X-ray. It wasn’t anything dangerous, but she dropped her oxygen levels quicker than I anticipated. It might be related to her pneumonia, and I just want to make sure.”
“Thank you!” her mother gushed. “Finally someone is listening to me. I’ve been telling everybody that something’s not right. They won’t do anything.”
“Well, I’m listening. We’re getting the X-ray. We’ll figure it out.”
And so the story continued with an almost expected plot. I wasn’t surprised at Jill’s mother’s claim that no one was listening. The vast majority of a pediatrician’s office practice is well-child checkups, runny noses, colds, and vaccinations. And I wasn’t surprised by her insight that something was not right. Mothers always know best. I was surprised by how blindly I had acted up to this point. When moms say something’s wrong, it’s true until proven otherwise. This is a belief I was taught early on. I was surprised I had missed so much. All the signs and symptoms were there, and I hadn’t completed the picture, the story line. My curiosity had finally been piqued in the OR, but to me, this was too late.
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