Counting Backwards

by Henry Jay Przybylo

  Behind the father, three chairs lined the wall. Nearest me, at the entrance, were two industrial-style armchairs—metal framed and with stout, straight backs and blue faux-leather cushions that coordinated with the décor of the curtains. Intended to provide a homey feeling while suitable for heavy use, the hard, plastic arms don’t quite measure up. Furthest from the door and angled in the corner sat a light cranberry–colored leather chair with soft cushions. The reclining feature does succeed in providing comfort, both to the appearance of the room, and to whoever sits in it. Not infrequently, I’ll catch a dad napping there. Mostly, I find moms holding and snuggling a child, providing comfort.

  The space between my patient and me was occupied by a parent. In my experience, that space is most frequently filled by a mother, simply because eight out of ten times, it’s mom who provides for the health care needs of a child. This space existing in pediatric health care is not normally present in the adult health care world, where families sit (or stand) to the side.

  Usually this space is like calm water, easy to navigate. Parents, although concerned and nervous, are also anxious to be of help and provide every bit of information necessary, allowing me to develop a safe and effective treatment plan for their child. Usually I ask the mother most, if not all, of the questions. Mothers provide for the majority of their children’s health care. Fathers—myself included—more often than not don’t know all the answers.

  “Does your child have any allergies?”

  “Uh . . . ”

  Once this space has been navigated, it’s on to the child so that I can complete my examination while establishing a relationship.

  Occasionally this space is not so calm. My hospital is a tertiary-care, pediatric hospital, meaning we are a final destination for the patient and, more, the parents. Community hospitals might not provide the necessary care, or the care in the community might fail to alleviate the problem. An unsuccessful or unpleasant experience with another system leaves patients, parents, and families not only anxious, but sometimes also angry or distressed. This situation is tricky to navigate, requiring insight into the reason for the transfer of care and the cause of the discontent, while demonstrating an ability to provide the appropriate care, assuring all that we can do better and showing compassion not just for the child, but for the parents.

  This bouncing boy’s mother sat with her back straight, her shoulders high, and her arms folded tightly across her chest. This wasn’t the appearance of an anxious, unknowing mom. In this setting, I’m accustomed to parents posing uncomfortably—sitting on the edge of the chair, with hands tucked under the backs of their knees—attempting not to appear too tense. No, this mom represented a funnel cloud ready to touch down, like a spring coiled tightly and ready to release all its energy with the slightest trigger. This mom was ready to strike, and I stood in her path.

  Her child had come in for a procedure on the penis—another one. In his three-year life, this was to be his third attempt at penile beautification, the first two done elsewhere, and this mom was clearly frustrated. Her frustration loaded the spring, and anybody who made the slightest out-of-step move was a potential trigger. As always, on entering, I introduced myself. The little boy’s father responded, while the mother sat still and quiet. Her gaze shot through me; her angst froze me.

  It amazes me how much penile pathology exists in young boys; still, I find it equally amazing, if not more so, how obsessed parents are with their sons’ penises—as if their boys would be condemned to a life of ridicule and assured of failure if any aspect of this mini-organ was just a little bit off. Fortunately for me, I am not a pediatric urologist. (Adult urologists have plenty of nicknames, from “dick docs” to “stream team” to “prick plumbers”; my favorite is “wee-wee whackers.”) The pediatric urologist must deal with many preoperative and postoperative visits, and the litany of questions and concerns that come with each. As a pediatric anesthesiologist, my contact time is normally limited to the day of the procedure.

  RECOVERING FROM THE INTENSITY of the mom’s gaze, I asked all the usual questions. The father answered while the mother sat, simmering quietly in the corner. I examined the boy, and then I started to discuss my proposed anesthesia care with his parents. I noticed that during his previous surgeries, he had not received caudal blocks for pain relief. I was instantly reminded of Casey, the master surgeon who is one of my legends.

  Casey’s patients were primarily children with penile issues, and the patients’ parents raved to him about their sons’ comfort lasting long beyond the recovery room, long after discharge from the hospital and their return home. The caudal block, a single injection of local anesthesia medication placed while under anesthesia (no discomfort) upon the nerves at the base of the tailbone lasts six hours or more. One particular block lasted so long that the first pain reliever was not necessary until sixteen hours after surgery.

  Casey had sought me out. “More satisfied parents! More caudals!” He wanted every patient that might benefit from the block to receive one. I followed his guidance, and I was proud that these children not only left my care pain-free; they also left the hospital and arrived home in comfort.

  But in this little boy’s mother on this day, my recommendation of a caudal block triggered the spring’s release. Angst or anger—I couldn’t differentiate—overflowed. The reason for her insistence that there be no block might have been a failed epidural block during her labor and delivery, or the common misconception that caudal blocks cause permanent paralysis. Untrue. If she’d had confidence in me before I mentioned the caudal block, I risked losing it by insisting that her son receive one. I chose another tack.

  During this time, the little boy continued to bounce up and down in the safety of his father’s arms, unaware of any controversy.

  I was convinced I could provide better pain relief after this procedure than the boy had received in the past. My easiest option was to leave well enough alone, drop the topic, and proceed without the block. But my first responsibility is not to the parents, but to the patient. I wanted this boy to receive the safest, smoothest, and most pain-free anesthesia possible. To return him to his parents awake and alert and pain-free was my goal. I pushed forward.

  My challenge in this case was determining how far to go in insisting that the parents accept my plan for care, and for pain relief—care above and beyond that of the child’s previous procedures—even in the face of doubts. Past the “See one,” continuing beyond “Do one,” and now sailing past “Teach one,” I was moving beyond the two thousand caudals performed and not one substantial complication. I proceeded.

  “This is one of the few times that I can remove myself as a physician and tell you, as a father, what I would do. I must tell you that, without any second thoughts, I would never let my son have this surgical procedure without a caudal block.”

  “Really?” the father responded. “But is it safe?”

  “I have performed thousands of these blocks without a single significant complication. If there has ever been a problem, it’s always been that the medication didn’t reach the exact area it needed to work properly. If this happens, I will give your son the medication I would have used if I had not performed the block.”

  “Hmmm.” A pause. “Well, I think we should try it.”

  Before the words were fully off the father’s tongue, the mother jumped forward from her seat. Her arms flew out and she glared at me with a look between accusation and total disdain.

  Then she said it: “I’ve heard these blocks can cause permanent injury.”

  “Never in my experience.” I have never cared for a patient who suffered permanent neurological injury from any nerve block. And I repeated that of all the blocks I have performed, I’ve never had any complications besides failure of the medication to relieve pain.

  “I will do what you want,” I continued, “but I strongly recommend this block. This is the single best manner that I can provide pain relief for your son.”

 
“Let’s go for it,” the father declared.

  The response was greater than a shift of the San Andreas Fault.

  The boy’s mother took a few steps toward the foot of the cart. She looked at her husband for a moment, then at her son, then back at her husband. Her right arm flew out in front of her, and she wagged her extended index finger directly at her husband and declared: “If anything happens, I want you to know it will be on your shoulders!”

  Attempting to leave on a high and confident note, I said: “Trust me. We’ll do just fine.”

  The pressure was on me to deliver. I walked past the curtain and, before turning up the hall, slid the glass door shut. I didn’t want to hear the discussion that took place once they were alone.

  After entering my pre-anesthesia note for the little boy, I wondered for the briefest of moments whether I had overstepped my bounds and pushed too hard for the caudal block.

  I completed a final review of the record, checked the consent, and walked back to the boy’s room. I asked if there were any final questions. The mother never returned to her chair and stood silently scowling in the corner. The father responded that everything was fine. I lifted the boy off the cart and carried him back to the OR.

  We walked through the double doors and I let out a long “Yesss!” I had taken the boy from his mother, and he wasn’t crying. This was good. I talked to him the whole time about favorite TV shows and books. I started reciting Green Eggs and Ham.

  As I placed the bubblegum-scented mask to his face, I kept speaking. I told him he might feel tingly and possibly even giggly, since he was breathing laughing gas. In a few seconds he was quietly anesthetized.

  The IV went in uneventfully; then I turned him on his side, while anesthetized. I carefully examined his back to make sure a caudal block was possible, that there were no congenital defects of the spine that would preclude my placing a needle into the epidural space and injecting local anesthetic. His anatomy was perfect.

  I looked at my anesthesia resident. Knowing what had transpired, she declined to place the block. At first, this disturbed me. How else can one learn? Then I considered that pediatric anesthesia wasn’t her interest, and that she wouldn’t likely ever perform this block in her practice. I had no problem placing the block. The needle slid in and the local anesthetic flowed smoothly. The case proceeded uneventfully. The surgeon did a marvelous job. This penis would heal just fine, with very little scarring; his would be a penis that any parent would be proud of.

  Most important to me, this boy awoke pain-free, and I transferred him to the recovery area.

  With a full schedule, I hustled on to my next patient. I stepped up to the gurney to a woman sitting on the edge. I looked to the floor and watched as perspiration dripped from her feet, which dangled in the air, puddles forming under each that coalesced in my presence. This woman suffered from hyperhidrosis, the real disease, which is nothing like the claims of underarm wetness. The perspiration in true hyperhidrosis is so severe that hugs feel like embracing a soggy towel, a handshake feels like grabbing a soaked sponge, and beads of sweat grow spontaneously. Clothes and shoes risk being ruined in one wearing.

  Botox, famous for its ability to prevent facial wrinkles, offers a therapeutic option, although expensive. The sites of greatest sweat production include the hands, feet, and armpits, as well as the gluteal fold between the buttocks. The many, widely spread nuisance glands causing the problem are injected with hundreds of minute amounts of Botox. The multitude of injections warrants anesthesia. The case was easy for me: an IV, milk of amnesia (propofol) for induction, and sevoflurane for maintenance. Soon I transferred the woman to the recovery room with a thousand, perhaps more, minuscule drops of blood visible. She awoke grateful.

  Next to her in the recovery room, my young patient from the earlier case sat on his gurney enjoying a popsicle. His mother sat at the foot of the cart, his father not in sight.

  “Well?” I said.

  “Well what?” Mom responded.

  “What do you think?”

  “He’s OK.”

  I needed to control myself. “OK? He’s great. It went perfect.”

  The next day, I was shocked to learn that this mother had mentioned that their hospital experience had been the best they’d ever had.

  THE REWARDS OF BEING a physician come to me from many directions. Most, but not all, come from providing patient care and knowing that I made a difference. Others come unexpectedly. A friend and previous colleague called to ask about a friend of his whose child had “special needs” and required anesthesia. I told him to have her call me. She did, and I must have allayed her fears and concerns. Shortly after, he sent me a letter referring to me as a “mensch.” An honor indeed.

  Some of my fondest memories come from watching others master the skills and techniques that I have taught them. I received a call one morning from a young doctor I’d trained, who was now practicing hundreds of miles away.

  “You saved a life during the night,” he said.

  “Wonderful. How did I do that?”

  He explained that a newborn had been transferred to his NICU. The infant was in respiratory failure and had a tiny mandible. This meant he was not able to breathe well. The neonatologists had tried many times but couldn’t intubate him. They couldn’t see the vocal cords. “They called me, and when I saw the baby, I remembered how you taught me the retromolar approach.” This is a maneuver on intubation to visualize the difficult airway. “I saw the vocal cords on the first try, and the tube went in without trouble. You saved that baby.”

  That phone call is my favorite teaching experience. It was a pat on the back, the reward for teaching, the fulfillment of the oath of Hippocrates by adding to someone else’s expertise.

  CHAPTER 14

  Reentry

  MOST OF THE ANESTHETICS ADMINISTERED TODAY continue to utilize an inhaled potent ether gas. For the patient, reentry to awareness entails reversing the chemical coma. I turn the vaporizer dial two clicks to the left, cutting the flow of the volatile anesthetic agent. The gas is literally breathed off mostly unchanged, and when its concentration in the body drops to sufficiently low levels, the patient emerges from anesthesia. This process takes place more slowly and is more readily counted in minutes compared to the seconds it takes for anesthesia induction. Akinesia (paralysis), if used, requires a reversal drug—hopefully, avoiding a syringe swap.

  Patients, and especially surgeons, want an anesthesia button that is pushed once at the start of a procedure to instantly induce anesthesia and, at the end of the procedure, is pushed one time again to turn the anesthesia off. We’re pretty close to instant anesthesia induction, but instant anesthesia emergence is still some way off.

  Dividing the aims of anesthesia into the Five A’s allows anesthesiologists to expedite the on/off goal, and to improve patient outcome and satisfaction. Treatment plans that avoid using volatile anesthesia gases, especially for procedures that do not invade the abdomen or chest, might shave some time off the emergence process. Avoiding the ethers might have other benefits. A person with persistent nausea and vomiting after previous gas-based anesthesia might benefit from not breathing a volatile agent, a known instigator.

  Using combinations of drugs that alter anxiety, amnesia, and analgesia can achieve the desired anesthesia effect but requires multiple drugs and exposes the complexities of consciousness. We form memories while asleep, but not while anesthetized by volatile gas, and we lose awareness while we’re awake during daydreams, as well as under the influence of azepams. There’s always a risk that a patient will retain awareness somewhere along the process of anesthesia.

  Not uncommonly, I’m urged by patients and families to “not use too much,” “to go light,” to provide “twilight,” or to avoid the gas anesthetics. Recent damning press has reported on cognitive dysfunction after gas anesthesia. Scientific studies to date don’t support this conclusion. I liken the control of anesthesia to light switches. I’m most comfortable assuming
all control of the patient. This is the toggle switch approach: either on or off, with no in-between. When I use a volatile gas, the patient is completely anesthetized, I’m in total control, and I’m able to deliver the patient back to consciousness with the lowest risk for complications.

  Veering from this approach, altering the depth of altered senses by decreasing the dose of anesthesia drugs administered simulates a dimmer switch. I relinquish total control of the patient. Neither the patient nor the proceduralist nor I possesses total control. As the dial on the switch turns, and it is not always turned by my fingers, the amount of drug needed changes, and at some point the patient enters the state of full anesthesia—a point not easily recognizable. Complications and even death result from failures to spot and promptly treat drifting blood pressures, aspiration of gastric contents through an airway not able to close, airway obstruction, or the cessation of breathing. And such “reduced” sedation is often provided without the presence of an anesthesiologist.

  Regardless of the type of anesthesia administered, I believe that assigning complete control of the patient to me ensures the safest outcome.

  THE TREND AWAY FROM surgery and toward minimally invasive, interventional care continues to grow. Replacing leaky or constricted heart valves is moving from open-heart surgeries to the cardiac cath lab, clipping cerebral aneurysms through craniotomies is shifting to the radiology suite for coiling, snaring cancerous polyps in the colon is transitioning from abdominal surgery into the endoscopy lab. And with these changes, the needs for anesthesia are changing, as are anesthesia techniques. The pre-anesthesia discussion between patient and anesthesiologist—what’s wanted, what’s needed, what’s advised—is as important as ever.

  Toward the goal of minimizing the effect of surgical invasions on the patient, arguably the most significant pharmacological advance in anesthesia in the last forty years came from a new and unique sedative, not a tweaked chemical formulation of an existing drug. Propofol, affectionately known as “milk of amnesia,” is poorly soluble in most carriers; it is dissolved in a lipid carrier that gives it an opaque white color. Its short action, five minutes, provides for a quick return to awareness and makes it ideal for sedation as a continuous IV infusion. Propofol provides two of the Five A’s: anxiolysis and amnesia. It provides no analgesia and actually burns on injection. Painful procedures require additional medications and techniques.