Sunday at the VA edition

[N.B.:  As our troubled VA system is currently in the news, I should say that this post makes reference to a very bygone era, by which I mean the Eighties.  The conditions described herein in no way reflect the status of our modern VA system.  I’m sure.  I hope.]

Not surprisingly, it took less than 48 hours after posting “Anesthesia isn’t Easy-1” before I heard from my nurse anesthetist friends.  And a few other anesthetists.  Quite a few, actually.  Unfortunately, the awkwardness of our medical lexicon precluded the appropriate repeated reference to our anesthetist colleagues (how many times can I write “anesthesiologist/anesthetist” in a 500 word blog post before even I stop reading the thing?).  It goes without saying (since it seems I didn’t say it) that pretty much everything I wrote in AIE-1 applies to our CRNA brethren.  There, I said it.

As I mentioned in that last post, a doctor’s early training is formative in many, many ways.  In my own experience, I came to love CRNA’s in general (and one in particular) during the second year of my general surgical residency. No, not the CRNA my future wife kept trying to fix me up with so that I’d quit asking her out. Different CRNA.

I was doing a rotation at the enormous VA Medical Center associated with my residency.  This was an institution that could easily serve as a setting for Game of Thrones or, maybe more appropriately, The Desolation of Smaug.  Built in medieval times, this fortress hospital was over a thousand beds and could be seen from space. It was somewhat past its prime.  By about a half century.  Many dusty corners, so to speak.  Actually, entire haunted wards.  Scary.  Dark.  Huge.  On one occasion I remember, when we sent a medical student to go find the patient who was using the central venous catheter so that we could clean it off and use it on another, really sick patient, the student got so lost we didn’t see him for almost a week.  We had to send a posse to a neighboring VA hospital for the catheter, I think.

Despite the incredible hugeness of the facility, it possessed an Emergency Room about the size of a broom closet.  This was specifically designed, I believe, to discourage our veteran  patients from considering the VA hospital as a potential site for emergency care. Which was an especially good thing, since despite the overwhelming hugeness of the facility, there was only one junior surgical resident on call in house on weekends. For all surgical specialties.  All of them.

Surgery call was especially exhausting due to the ridiculous policy that the surgery resident was required to respond to all Code Blue calls throughout the hospital, specifically because there were no respiratory therapists or anesthesia personnel in house.   So the surgery resident was required to do all intubations (establishing emergency airways in patients).  This was particularly problematic since many (most) junior surgery residents pretty much suck at intubations.  And since nobody else on the code team could do anything until the patient was intubated, some codes were very, very brief.  And even though over half of the wards had been closed down, there was no consolidation of the active wards.  Patients were scattered through two towers of a dozen stories each, with an elevator system dating back to the Civil War.  Any attempt to wait for the one functioning elevator car and you’d invariably arrive in time to pronounce the patient dead.  And since this was the VA hospital, it wasn’t unusual for there to be two or three codes in an hour, at any time of day or night. We were all in great shape as a result.  The original stairmasters.

One time as a second year resident,I found myself on call, alone, on a sunny Sunday afternoon.  I was running around doing all the scut work that we had to do in those days, drawing arterial gases on the ICU patients, admitting the preop patients who would have surgery during the coming week, that sort of thing.  The sort of thing that could easily keep four or five junior residents too busy to eat or sit down.  I was doing pretty well, thanking my lucky stars that there miraculously hadn’t been any codes to interrupt my work, when I simultaneously heard myself stat paged overhead and my beeper went berserk.  I didn’t recognize the number.  Which turned out to be the ER.  “We have an ER?” I asked the frantic nurse on the other end of the phone.  “Get down here STAT!”  was her reply.

I had to ask a janitor where the ER was, but I got there.  When I arrived, I saw an elderly internist/ED doctor and several nurses crammed into the tiny space around the one stretcher.  Sitting up on the stretcher was the largest vet I had ever seen.  Easily over 400 pounds and like six six, he was hunched over and breathing really, really fast.  He was also making a sound that no person should be making–a high-pitched crowing sound called stridor.  This, I remember thinking, is not good.  “Thank god you’re here,” the ancient internist said, turning to me.  Nobody had ever said anything like that to me before.  “Not really,” I remember thinking.  “His dentist sent him over,” the internist continued over the loud crowing sound of the man struggling to breathe.  “Really?” I said, trying to sound calm.  “His dentist?”  “Yes, yes,” the internist continued, pulling me up to the stretcher in an effort to get me to take charge.  “He thinks he might have Ludwig’s angina.”  I nodded sagely.  “Could be.  He might.”  No idea what Ludwig’s angina might be.  Looked bad, though. “What would you like me to do?  He need a line?” I asked.  I was really good at starting IV’s.  “No, no,” the internist said, gobsmacked.  “He’s got an IV.  You need to take care of his airway.  Right now!  Or he’s gonna die!”  Oh.  I remember the patient following this conversation with great concern.  I think he felt pretty much as the internist did.  “Of course,” I said, reassuringly.  “I’ll be right back.”   Then I ran away as the internist asked where I was going.

I ran to the OR.  There was no chance that I was going to be able to intubate this guy, of this I was sure.  Besides the fact that the man was huge, panic-stricken, and had an airway that was swollen almost completely shut–I sucked at intubation.  Just ask my last three code patients.  Except you can’t, because they’re dead.  The only hope was to grab an emergency tracheostomy tray so that when the guy was unconscious from hypoxia and not quite dead, I might be able to do an emergency trach.  About one chance in a million, give or take.  Still better odds than me successfully intubating the guy awake in that ER.

I slid around the corner into the OR and stopped dead in my tracks.  Usually, the OR would be dark and empty on a Sunday afternoon.  But the lights were on.  I ran into the anesthesia office and saw two huge shoes on the desk.  Tiny Ted was asleep in the chair.  Ted was the Chief and only CRNA at the hospital.  Actually, he was the entire anesthesia department, functionally speaking.  A grizzled bear of a man in his late forties, Tiny Ted was pretty much the only person interested in actually administering anesthesia to our patients.  The anesthesiologists in the department specialized in explaining why our patients couldn’t have surgery.  If you really wanted to operate on someone, you got Ted.  He was good natured, always wanted to work, and was supremely capable.   “Ted!” I yelled at him, shaking him awake.  “What are you doing here?”  “Stocking the drawers, getting ready for tomorrow,” Ted said, coming awake.  “And staying away from my wife.  Why?  You look like you’re about to piss in your pants, Geller.  What’s up?”  I explained about the patient with Ludwig’s angina.  “Nasty,” he commented, rubbing his stubbled chins.  “Let me guess, Geller–you came here to grab a tray so you can do a slash trach down in the ER?”  I nodded sheepishly.  “Why don’t you just shoot him in the head?  Be more humane, less messy.  Less likely to kill him, too.  I heard about your last trach, Geller.”  {see “Equinimity“} He let me squirm for a minute before slapping me hard on the back.  “Get your patient up here and set up a room for a trach.  I’ll give you a hand.”  “Thanks, Ted,” I said, relieved.  “Where are you going?” I asked.  “Get some coke,” he said, leaving.  “You’re thirsty?” I asked.  “Not that kind of coke, Geller.”  Oh, I thought.  Maybe I caught Ted at a bad time.

With the help of two orderlies, I got the patient lying semi-reclined on an operating room table.    I had set up my instruments and a scalpel, which the patient was staring at fixedly.  He was also breathing about forty times a minute and his stridor was even higher pitched than before.  He looked about twice the size of Ted, and Tiny Ted was a rather big man.  That’s why we called him Tiny Ted.  Also, I noticed at this point, the patient had the interesting anatomic feature of having no visible neck.  His head apparently sat directly upon his chest.  Great.  “This here,” Ted said, interrupting my rising sense of panic, “is the entire stock of cocaine in this institution.”  He held up an impressively large vial labelled 4% Tincture of Cocaine.  “Can we talk about that later, after this?” I asked him.  I really needed Ted’s help.  “This is what’s going to happen,” Ted continued, ignoring my comment.  “I am going to take one shot at intubating our friend here.  Exactly one shot, period, amigo.  If I can’t tube him, it’s your turn.”  He stared at me.  The patient stared at me.

I nodded solemnly.  “And then he’ll die a horrible, bloody death,” I thought to myself.

“And then he’ll die a horrible, bloody death,” I heard out loud.  I thought somehow my thoughts had become audible.  But no, it was just Tiny Ted saying what we were both thinking at that point.  The patient appeared somewhat more distressed at this.  “Don’t worry,” Ted said brightly to him, “you’re going to do fine.”

“Probably not,” I thought.  “Just kidding,” Ted said.  “But I’ve got cocaine.  You ever do coke?” he asked the patient.  The patient barely managed to shake his head, being pretty much fully occupied with struggling to draw his last breaths through an airway about the width of a swizzle stick.  “You’re going to be fine,” Ted said again.  Tiny Ted, the master of mixed messages.

At this point, I took up my position over the patient with a #10 scapel in (trembling) hand.  Ted lowered the head of the OR table as the patient’s eyes, now big as saucers, never left mine.  Ted began a complex ritual of spraying cocaine into the patient.  This was accompanied by a soothing Hindu prayer chant, intermixed with an off-key rendition of Tupac’s “God Bless the Dead.”  (Actually, I made that last part up as a shameless, subliminal pitch for my first novel.  He actually was tunelessly singing “White Lines (Don’t Do It)” by Grandmaster Melle Mel.)  After something intravenous, Ted began a process of inserting a series of cocaine soaked cotton tipped applicators deeper and deeper into the patient’s nose.  Eventually he had about four sticking out of each nostril.  The patient seemed happier.

“Here goes nothin’,” Tiny Ted announced as he dramatically took endotracheal tube in hand and waved it over the patient’s face.  The patient had his eyes closed.  Seemed like a good idea, so I closed mine and silently promised God all sorts of stuff if He didn’t make me cut open this man’s throat.  A chocolate ice cream sundae, if the occasion arose.  And other stuff, too. Like learning to intubate better.

“Done,” Ted announced.  I opened my eyes.  There was a tube sticking out of the patient’s nose.  The stridor had stopped, replaced by the sound of easy, ventilator-assisted breathing. Ted was busy pushing enough muscle relaxant through the IV to put down an elephant for a month.  “This should keep him from pulling the tube out until I get of here.  After that, he’s your problem, Geller.”  I nodded and put away my scapel.  I could have hugged him, but it would’ve been awkward.

“Thanks, Ted.”

“No problem, Geller.”