Despite its short action, propofol is a dangerous drug, as evidenced by Michael Jackson’s death by overdose, a reminder that vigilance when altering alertness remains a necessity. The biggest advantage of this drug is that it speeds reentry. All the other drugs I use to treat anxiety and amnesia entail a hangover period, in which the patient feels altered and unable to perform normal tasks. With propofol, there is no hangover. Propofol allows consciousness to return rapidly and intact, with the added benefit of reducing postanesthesia nausea and vomiting.
MY SON’S REENTRY TAUGHT me a valuable lesson. He received remarkable anesthesia care and emerged intact and well. But not long after, he confided to me that he had been in pain after the procedure. In my experience, craniotomies surprisingly lack pain, even though bone (the skull) is being cut—normally a cause of significant pain. He enlightened me. Most of the craniotomy patients I’ve cared for had brain surgery toward the rear of the head. My son’s surgery required a frontal approach that cut through the muscle of the forehead, the temporalis. Every facial grimace included contraction of that muscle, and thus pain. Narcotics could provide the needed analgesia, but at a price of possible sedation, an undesired side effect possibly masking assessment of brain function.
Karl Koller, an Austrian ophthalmologist, was an early adopter of local anesthesia. In 1884 he experimented with injecting cocaine into his own eye. I’ve injected lidocaine into my own lacerations to lessen the pain of wound suturing. The pain relief team responded to my son’s pain by injecting a local anesthetic near the nerve that innervates the muscle in question. The result was spectacular.
The actual advance that made prolonged pain relief by injected local anesthetics successful came by way of placing a needle accurately near a nerve. Originating as a method to detect submarines during wartime nearly a century ago, sonar (originally named for “sound navigation ranging”) underwent a variety of technological advances that led to a probe the size of a pack of playing cards. When held in the hand and slid on the skin over a nerve, it creates a sound-generated video showing a needle’s position and demonstrating local anesthesia during injection bathing the nerve deep in the body. There is no nerve that can’t be reached with an ultrasound machine. Using ultrasound, a well-trained anesthesiologist can provide pain relief to some of the most difficult patients—for example, those with cancer in the abdomen and those with incapacitating back pain.
There is a deep-seated belief that anesthesia steals something from the patient’s mind. Reuniting family with patients in the recovery room too early only strengthens this erroneous belief. The gas anesthesia agents wear off in a toe-to-head pattern. The patient is able to move and even respond to commands very soon after surgery, but recognition requires the highest brain function and is the last to return during reentry. A patient’s inability to recognize family can be frightening.
One uncommon source of distress during reentry is delirium. Even while appearing fully awake, a patient emerging from anesthesia may not be oriented to person, place, or time. The cure is not to administer a “tincture of time” to allow the delirium to resolve, but to sedate the patient to enable slow reentry. After a brief sleep, the patient emerges peacefully, intact, and able to recognize family and friends.
Reentry is just as magical as induction. My faith is a necessity in my career as an anesthesiologist. After more than thirty years of practicing, I’m no closer to explaining the mechanism by which the gas I provide anesthetizes, and I’m as baffled as ever about how the drugs I administer selectively alter memory. When I emerged from my own experience of anesthesia, what I needed most was to see my wife, her face in conflict, concern for my well-being obvious, and overwhelmed by that gentle smile of love that provides more comfort than any medication. Observing my patients happily reuniting with their spouses, parents, and loved ones, and in better condition than on arrival, fills me with an enduring joy.
CHAPTER 15
Safe Travels
NICK, THE UNFORTUNATE HALF OF AN UNEQUAL twin gestation, was born with the VACTERL association, a constellation of congenital defects that tend to occur together. The defects include anomalies of the spine, an imperforate anus, heart malformations, disruption in the path for eating or connection of that path to the trachea, abnormal kidneys, and deformed arms. Nick suffered from the life-altering radial hypoplasia—a misshapen forearm with no thumb, creating a minimally functional hand—and a life-threatening congenital heart defect.
Nick’s first anesthesia experience came shortly after birth for the repair of a tracheoesophageal fistula, which allowed fluid to pour from his stomach directly into his airway, avoiding the cough protective reflex and flooding his lungs. He returned for anesthesia many times thereafter. Pediatric anesthesiologists train for these neonatal cases, which involve multiple organs and demand precision.
I can’t remember the first time I provided Nick’s anesthesia care. It was early in his life, and I recall a tracheostomy in place—his voice box narrowed below his low-functioning vocal cords, requiring a tube in his neck that allowed free unobstructed breathing. After the procedure, I talked with his parents, both in recovery and later in his room. They asked if I would be able to care for Nick when he returned for his next procedure in a few months. “I’d be honored,” I said. “Just give me a call.” I believe Nick’s parents felt reassured that someone was concerned about Nick as more than just a patient or condition. Anesthesiologists often limit their discussions to the case or the condition. I spoke with Nick’s parents about their son.
A couple of times each year, I would receive a phone call from Nick’s father—“Hey, Doctor Jay, are you available?”—and Nick would undergo another procedure. After every anesthesia, when I spoke with Nick’s parents, it was his mom who did most of the talking, so I found it curious that his father always made the phone call. As Nick grew, so did the number of times I cared for him. My response to Nick’s father was always: “When and where?” followed by “I’ll be there.” I would mark my calendar for the date.
Once, after the usual exchange, I asked: “What’s Nick coming in for?” A short pause ensued. I think his father needed to catch his breath. Then he said: “For a revision of his heart. A valve is too narrow.” I felt his anxiety. This was the third time surgeons would enter now ten-year-old Nick’s chest, and with each procedure the risks rose. Nick was only halfway to adulthood, and he faced multiple surgical procedures in his future.
Approaching a medical procedure that requires anesthesia is stressful for everybody: the patient, the family, the surgeon, and me. The day I no longer feel stress when caring for a newborn is the day I should search for a new career. Babies’ conditions change in an instant, with little to no time to make a treatment decision. The old truism is this: It’s hard to kill a baby, but it sure is easy to hurt one. The TTI (time to injury) from the start of wavering vital signs to lasting harm is a fraction of what it takes to harm an adult. Anesthetizing babies requires extraordinary vigilance.
For the patient, anxiety ends with the loss of consciousness, a magical and momentary transformation. But for those left behind, the anxiety is unrelenting. Waiting for the time of reunion slows the clock, with seconds seeming like minutes, minutes like hours.
AS I ENTERED THE pre-anesthesia holding room, Nick sat up on his gurney, and for the tiniest fraction of a second a flash of light bounced from his chest. In this small, dark room in the interior of the hospital, lacking any natural light, the cart occupied most of the space, with only a couple of feet on the far side for his parents to stand and an equal amount on my side. The only light in the room streamed through a door and reflected off of Nick’s chest.
Cheerful as always, Nick’s parents greeted me with familiar smiles, even on this day of heightened anxiety.
With time of little concern, I slid a chair onto my side of the gurney. Sitting rather than standing creates the illusion that a physician spends more time with a patient. For me, sitting means more. It puts me at eye level wi
th my patient, rather than peering down from above, and allows me to speak with, not to, the child. I hope it’s taken as I intend it: as an indication of genuine caring and assurance.
As we spoke, I noticed that the glare from Nick’s chest came from a gold Saint Christopher medal—the Catholic patron saint for travelers. The medal showed Saint Christopher carrying a baby—the baby Jesus—on his shoulder with a caption intoning protection. Surgery is a journey for all involved, and the faithful seek divine intervention and invoke a guardian for spiritual comfort. At the end of our discussion I turned to his parents.
“Would you like Saint Christopher to stay with Nick through the procedure?”
“You don’t have to,” his mom responded.
I persisted. “It’s no trouble.” This was my attempt at lessening his parents’ anxiety.
“Thank you.”
With the Saint Christopher medal in hand, Nick and I headed for the OR. When we got there, I pinned the medal to the sheet covering the OR table, next to Nick’s head.
Many hours later, the procedure very long because of scarring from previous surgeries, Nick was transferred to the intensive care unit. I was upbeat talking with his parents because everything had gone so well. I went to my office to complete some of the paperwork that medical school doesn’t warn you about, fulfilling all the bureaucratic requirements.
My pager went off; the intensive care unit was looking for me. Thoughts of complications raced through my mind. I ran through the list of all the possible problems and how to treat them as I rushed to a phone.
“It’s Doctor Jay. Someone paged me. Probably about Nick.”
“It was me, Doctor,” the nurse caring for Nick said. “I was calling because the parents asked if you knew what happened to the Saint Christopher medal.”
“Oh, shit!”
My pulse pounded worse than if there had been a complication.
“Excuse me?”
“I’ll get back to you.”
Before the receiver settled onto its cradle I was running through the halls, back to the operating room. It had been fully cleaned, the linens and trash removed. I searched the shelves, carts, and drawers to no avail. I asked a nurse who was stocking the room’s supplies and hadn’t been part of the case if she had any idea where the medal might be.
“I didn’t see any medal, Doctor. I just got here.”
The nurses from the case had left, so there was no help. My heart sank.
“What happens to the linens after the case?”
“They go to the soiled-linen utility room. It’s right behind the anesthesia supply room.”
I had passed this room thousands of times before, unaware of its purpose. I hoped to get there before the laundry was removed. Breathless when I arrived, I opened the door and my eyes landed on a mountain of red. The dirty laundry from each case was placed in a large red plastic bag and brought here. The back wall of the room, about twenty feet in length, was covered with dozens of these bags containing the sheets, drapes, towels, and blankets from all the day’s cases. They formed a massive pile at least five feet high. Thinking those from the most recent cases were likely on top, I began pulling the bags down and searching them one by one. No Saint Christopher. After ten bags or so, I gave up.
With my head hanging, I dragged myself to the ICU.
I mustered the courage to look at Nick’s parents. “I’m sorry. I looked everywhere,” I said in a voice reserved for relaying horrible news.
“Don’t worry, Doctor Jay,” Nick’s mother said. “It wasn’t that important.”
She appeared sadder for me and my bumbling ways than for her own loss.
“It was, and this is just inexcusable.”
“No, it’s not. Really, it isn’t that big a deal.”
Despite being proud of the medical care I had provided, despite Nick’s outcome, I left defeated.
“What’s wrong?” my wife asked at dinner that night. I couldn’t hide my disappointment.
“I lost God today.”
“What?”
“I lost a child’s Saint Christopher medal.”
I relived the events of the day and felt miserable.
Nick recovered well and went home in less than a week.
I LANGUISHED OVER THAT medal. I felt the pain as if that Saint Christopher medal was pinned through the skin on my chest, a constant reminder of my failing. The concept of no good deed going unpunished came to mind. It’s easier not to take objects of value, objects of comfort for either the child or the parents—from blankies to stuffed animals to religious icons—back to the procedure area with the kids. Then nothing can be lost. But that’s defeatist.
All the books and articles ever written about children and anesthesia teach how to provide safe pediatric anesthesia care, but none teach how to care for the kids and their parents. I was determined to hold fast to my belief that any amulet, talisman, prayer book, or other object of faith that might ease a family’s anxiety could be taken into the OR and remain near their loved one’s head throughout. I committed myself to making sure no patient ever lost such a talisman again while under my care. I have lost nothing since.
ABOUT SIX MONTHS LATER, a message taped to my office door listed a familiar return number.
“Hi, Doctor Jay. Are you available . . . ?” Nick’s father, always his father, asked.
“Absolutely.”
He was as gracious as ever.
“Well, I am happy you still want me.”
“Why would we change?”
The case was a small follow-up procedure, and when the day arrived, the surgery was uneventful and Nick was soon in the recovery room.
About a half an hour later, the recovery room paged me. The nurse was asking me to go see his parents again. When I arrived in the recovery room, they were beaming.
Nick’s father looked at me and asked: “Doctor Jay, we were wondering if you knew where this Saint Christopher medal on Nick’s bed came from?” He was holding the medal.
I was stunned. A smile grew on my face.
“God’s work is mysterious,” I said.
As I walked away, the pain of that lost Saint Christopher medal piercing my skin evaporated.
FIVE YEARS PASSED, and one day I received a call from our administrative assistant, asking if I could stop by the office. There stood Nick and his parents. They were in town and had stopped by to see me. Nick looked wonderful. He wore a high-necked jersey, so I couldn’t see if the medal was around his neck. But his parents hugged me, deeply, and that’s what keeps me coming back.
Acknowledgments
Thank you to Leslie Rubinkowski, who directed my transition from medical writing (“This is a 16 y/o male who presents with RUQ pain and is to undergo a laparoscopic, possible open cholecystectomy . . .”) to writing for a general audience. To Patsy Simms, who accepted me into the Goucher MFA program. To Frank Seleny, Casey Firlit, Andy Roth, and many other colleagues, who have inspired me through the years. To Diana Hume George, Dick Todd, and Suzannah Lessard, who mentored me, and especially to Madeline Blais, who in addition to mentoring me insisted on the title. To Joy Tutela and the David Black Agency, who saw a glimmer of hope in my writing, and to Matt Weiland at W. W. Norton, who polished my thesis into this work. And to the many of thousands of patients who allowed me to enter their lives and provide their care, I am forever grateful.
A Note on Sources
The list that follows is not meant to be exhaustive, but instead represents an overview of the resources I used in researching each chapter.
INTRODUCTION
Anesthesia in the United States 2009. Schaumburg, IL: Anesthesia Quality Institute, 2009.
Bigelow, H. J. “Insensibility during Surgical Operations Produced by Inhalation.” Boston Medical and Surgical Journal 35, no. 16 (November 1846): 309–17.
CHAPTER 1 | A DEEP SLEEP
Ball, C. M., and R. Westhorpe. “Ether before Anaesthesia.” Anaesthesia and Intensive Care 24, no. 1 (February 1996): 3.
Discovery of Anesthesia by Dr. Horace Wells: Memorial Services at the Fiftieth Anniversary. Philadelphia: Patterson & White, 1900.
“Dr. C. W. Long, the Great Discoverer of Anesthesia.” Atlanta (GA) Constitution, October 13, 1889, 8.
Duncum, B. M. “Ether Anaesthesia, 1842–1900.” Post-graduate Medical Journal 22, no. 252 (October 1946): 280–90.
Eckenhoff, J. E. Anesthesia from Colonial Times. Philadelphia: J. B. Lippincott, 1966.
Fenster, J. M. Ether Day. New York: HarperCollins, 2001.
General-Anesthesia.com. Accessed December 17, 2015. http://www.general-anesthesia.com.
Haridas, R. P. “Horace Wells’ Demonstration of Nitrous Oxide in Boston.” Anesthesiology 119 (November 2013): 1014–22.
Leake, C. D. “Valerius Cordus and the Discovery of Ether.” Isis 7, no. 1 (1925): 14–25.
Lewis, J. H. “Contribution of an Unknown Negro to Anesthesia.” Journal of the National Medical Association 23, no. 1 (January 1931): 23–24.
Plomley, F. “Operations upon the Eye.” Lancet 48, no. 1222 (January 1847): 134–35.
Roland, C. G. “Thoughts about Medical Writing XXXV. ‘Let’s Call It Hebetization.’ ” Anesthesia and Analgesia 55, no. 3 (May 1976): 366.
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