Anesthesia is Pretty Difficult (5)–and Reading Can be Hard, too

Anesthesia is the scientific study of the subtle screw-up.

Same anesthesia rotation, different day, same inappropriately confident practitioner (me) today assigned to the gentle care of an eighty-two year old gentleman scheduled to undergo a routine hernioraphy.  Did I say routine?  Why yes, I did.  Hell, people, we do this shit a thousand times a day, let’s put this truck in D and get this done…BgicidBCQAAGm96

First case of the day, I’m a little late arriving to the break of dawn party that is the OR at this fine Midwestern University Hospital (17 year old Vega only starts by popping the clutch as I roll downhill), surgeon is annoyingly early and already pacing about, giving me that smile and saying, “Hey, take your time,” which means “Move your ass or I’m filing out this ‘Reason the Case was Delayed form.’ ”  I’m moving my ass, but this eighty-two year old ain’t a spring chicken, he’s taking about twenty minutes just to assume the position on the OR table so I can put in my obligatory spinal.  (Because, remember, everybody here gets a spinal.)  As Nurse Slowly Helpful helpfully but slowly helps patient curl up on his side “just like a baby or a comma” I’m marveling at her mastery of the mixed metaphor as I run in my mandatory liter of IV saline.  This eighty-two year old is on beta-blockers (who the hell isn’t?) and has the essential hypertension.  I’m about to relieve him of his spinal-cord mediated vascular tone with my spinal anesthetic, so in goes the vascular volumizer in anticipation of this physiological phenomenon.  An ounce–or liter–of prevention, you know.

Finally, the patient is positioned with Nurse holding him with maternal tenderness in fetal/comma position, I’ve got my gloves on and precalculated dose of magic local anesthetic drawn up as I notice Surgeon With No Home Life filling in the blanks of the “Case Delayed” form, but before he can sign illegibly I’ve done my Modified Taylor Technique thing and say, “DONE!” as I dramatically strip off my gloves, standing up to help Nurse  Nurturing reposition elderly widower patient with murmured sweet kindnesses (“See, that wasn’t so bad, was it?”) onto his back and crank the bed into the crazy angle that will give my man here just the right level of unilateral hernioraphy without hurting, perfect regional technique.  I’m thinking that, ‘Not so bad at all, no sirree. Damn, Geller, that guy was calcified and old and scoliotic and that was pretty sweet, first try and boom, baby, I could probably give a spinal to Michelangelo’s David if somebody could get him off that pedestal and lay him on his side for thirty seconds.’ Or something along those lines as I do my post-spinal first set of vitals-BP 176/90-well, you knew the old geezer had the hypertension going in, no problem, spinal will fix that, too.  I check my level and, of course, it’s perfect, so I pointedly announce to Surgeon Suddenly that we’re all set, he can scrub if he wants to get things started, big day of surgery ahead, wink, wink.

As the nurse is prepping the patient, I ask him how he’s feeling as I lovingly apply nasal cannula and he smiles at me upside down and says “Good,” like he knows that he’s in the hands of someone who’s taking really good care of him and he really  appreciates me, so I turn smiling to my drawer of a million medicines and select my little glass ampule of ephedrine from the neat little cubbyhole that is its special home, glance at the label as I crack the top and draw up my “just-in-case, never-hurts-to-be-ready, hell-it’s-not-my-money” pressor and dilute it 10:1, labelled and leave it lying on my little work space.

I’m humming to myself and glancing at the schedule to see if I can use a spinal on the next case (of course I can) as surgeon checks for effective anesthetic by pinching patient with pointed Adson tweezers, I nod at him with a smile as my patient remains oblivious to this assault.  Surgery ensues.  I recheck ancient patient’s BP, now 110/72.  See, I knew that the spinal was working and his hypertension is now normotension and what’s better than that, huh?  I look down fondly on my patient, now realizing that he looks just like the grandfather I never knew as he softly snores in contented comfort.  Sigh.  Isn’t anesthesia great?

“I think I might be sick,” patient mutters and I ask him “Excuse me?” noticing the slight sheen of perspiration on my Grandad’s forehead.  “Just a little queasy,” he says, smiling apologetically and I nod sympathetically as I recheck his pressure and-what do you know?–BP now 98 over don’t bother to notice because obviously it’s on its way down so I spin and push a little ephedrine, because I knew this was going to happen, I’m prepared.  I lovingly dry sweat from my patient’s brow with gauze and give him my reassuring smile but I’m noticing he’s looking a little pasty in his pallor.  Let’s just recheck that BP though it’s only been two minutes since the last one and–what the hell?– his pressure’s eighty?  That can’t be right, I pushed the pressor, should be working by now, let’s try that BP again and now it’s 70 and now I’m the one suddenly nauseous and I feel sweat appear on the back of my neck as I push half the remaining syringe of ephedrine.  I lean over my Poppa and ask, “How’re you doing?”

He looks me straight in the eye and says, “I think I’m dying.”  He seems sincere about this.  I check his BP, which is now somewhere south of seventy and I’m forced to agree with his clinical judgement.  A cold trickle of sweat runs down my back as I call my attending.

Kindly attending anesthesiologist appears and is immediately concerned when he sees the abject fear in my face.  “What’s up, Geller?”  Well, I explain, not my patient’s blood pressure though it should be because I’ve given him all this ephedrine (I hold up nearly empty syringe) but his pressure just keeps dropping and he thinks he’s dying and he looks like crap and I think he might be right and–

“Hold on.  You gave him ephedrine?’  I nod.  “Show me.”  I hand him the syringe.  “No, show me the vial you drew this up from.”  I look around and find the vial in the little plastic can attached to my cart and hand it to him as I sweat semicircles under my arms.

“Everything okay up there?” Surgeon asks, looking over the drape at our little tete-a-tete.

“Sure, no problem,” Anesthesia Attending reassures.  He turns to me and shows me the vial.  Sotto voce, he says to me, “This isn’t ephedrine.  It’s chlorpromazine.”

“WHAT?  Of course it’s ephedrine, I looked at the label,” I stammer as I look at the vial that says “Chlorpromazine” pretty clearly right there on the label.  No way, I’m thinking as I scan my drawer, noticing for the first time that even though every little vial is color-coded for safety, chlorpromazine and ephedrine just happen to be the exact same color and hey, look at that, they’re also right next to each other in the little cubbies, isn’t that just great, maybe the person who stocks this shit just missed a little in his underpaid, rushing through his job stocking my damn drawer.  Stop, Geller, just think–but I’m having a hard time thinking because the OR just turned to shades of gray and I’m hearing a roaring sound in my ears as I recall from Pharmacology For Fools Like Medical Students 101 in a sudden flash that chlorpromazine is an alpha blocker, strange the little facts that come rushing back from memory, especially since alpha blockade is the exact opposite of what my patient needed, OH MY GOD I’VE KILLED GRANDPA!  I drop heavily onto chair reserved for incompetent anesthesia wanna-be’s and seriously consider throwing up.

Meanwhile, Anesthesia Attending (a man who can actually read a label, not just pass that ampule in front of his face and seem to see it) has swung into action and is giving my patient real ephedrine straight up and wide open fluids and turns to me, saying “Go take a break, Geller, you look like you’re going to puke.”  I nod and take his advice.

When I return, only a little relieved that there’s no code cart outside the door, Anesthesia Attending is smiling.  “He’s fine, Geller.  Actually, I charted your chlorpromazine, he was nauseous, not completely out of line, there,” but I know he’s just trying to be nice.  Actually, it was exactly the wrong thing and it’s only by the grace of God Almighty that I didn’t kill this man.  “Pressure was low there for a while, I think he should stay overnight, maybe check some enzymes, make sure…”  Make sure I didn’t give the guy an MI, he’s kindly not finishing in his sentence.  I nod and thank him as I take over my case again.  Anesthesia Attending gives my shoulder a reassuring squeeze as he leaves with a smile that clearly says, “You fucked that up, Geller.”

I stayed the night with my kindly old grand-dad.  He thought it was a little weird, I’m sure, that this twenty-something year old wanted to hang out and play cards and kept looking at his bedside monitor as he told me about what he did in the war and his kids and a lot of other stuff I don’t remember because I was just so damn grateful the old guy didn’t die on me.

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