The Subtle Science of Sedation

As a general sugeon trained in a specific era and at a particular type of academic institution, I was taught that I should be able to do everybody’s job in the hospital just a little better than the folks whose job it was to do just that thing full time and to the exclusion of everything else after spending many years learning to do just that stuff.  It was believed that in this manner, we could protect our vulnerable, recovering patients from all the other doctors and health care professionals who didn’t care as much about the patient as we did.  With the foregoing mindset, I launched upon a two month rotation on the anesthesia service of a very large, very academic medical center.  One can easily foresee that this was not to go very well.  Not well at all.  Anesthesia practice is predicated on a team approach, an “all-for-one,” “we’re all in this together for the good of the patient,” approach. If an anesthesiolgist (or anesthetist) is having difficulty with an intubation or the patient takes a sudden turn, he or she is trained to immediately seek the assistance of a colleague.  Ego is put aside for the good of the patient.   I was trained to take a different approach.

For reasons that still elude me to this day, during this anesthesia rotation I was permitted to manage patients with an extraordinary degree of independence.  This may have something to do with the fact that I had no official supervisor.  I fell through the cracks, in a way, and the result was that I managed the anesthetic of quite a number of patients with a degree of independence not even given to anesthesia residents until their last year of training.  The physicians directing me thought that everything would be okay if they just assigned me the simplest, most straight-forward cases.  Interesting point, though, is that there is no such thing as an easy case for the truly incompetent.

Many cases come to mind.  It should be noted that I did this anesthesia rotation during a time period and in an institution that held the technique of regional anesthesia in very high regard.  That is, every case was approached with the attitude of “Why not use a spinal?”  So I did a lot of spinal anesthesia.  I got, I thought, very good at spinal anesthesia.  I could place a spinal in a couple of minutes on patients of every age and body type.  I was instructed in various approaches and was fairly skilled at several of them.  Wherein lies the problem.  The technique of anesthesia is not difficult to master, it is the practice.  As a surgeon in training, learning technique was what I did.  I didn’t have a clue about anesthesia practice, however.

On one Monday morning, I was assigned to provide anesthesia to a patient undergoing an open knee procedure to be performed by the Chairman of Orthopedics.  It should be noted that the Chairman of Orthopedic Surgery was equivalent to Tutenkamen of ancient Egypt.  He was easily the institutional equivalent of The Chaiman of Thoracic Surgery (see “Mommas, Don’t Let Your Babies Grow Up to be Surgeons”), but more powerful.  Therefore, this assignment surprised me.  I had been on the anesthesia service for several weeks and was looking good. (Definition of looking good:  Nobody knew who I was.  That is, I hadn’t been noticed at all since I hadn’t killed anyone yet.  Close, but no permanent loss of life.)  Even so, this was a plum case, usually assigned to a senior anesthesia resident.  But the seniors were all away at conference and the administrative anesthesiologist had no idea who I was, he just knew that I wasn’t a junior anesthesia resident and assumed I, therefore, must be the guy.  I shrugged and trundled off to see the patient.  He turned out to be a twenty year old football player who had blown out his knee in practice.  Nice guy. Very large.  Muscular.   I introduced myself, did my preop assessment, and informed him that I’d be giving him a spinal anesthetic, of course, since I gave everybody a spinal anesthetic.  The patient was fine with this.

Placement of the spinal went great.  It always did, I was pretty good at it.  I got the patient comfortably positioned on the OR table and started in on my hypnotic “You are getting sleepy” dialogue with the young patient as I began to infuse a little hypnotic potion in his IV.  Again, this was the eighties, when about the only IV drug for this sort of thing was Valium, a drug which was notorious for its great variability in effect when given IV, particularly on young, anxious individuals.  Like football players undergoing sugery.  I checked the efficacy of my spinal anesthetic and was pleased to note that I had achieved a unilateral (one sided) block to a level of about the groin.  It was even on the side to be operated on.  Perfect.  I was proud of myself.  I had dosed the spinal for a duration of two hours, as the Chief Orthopedic resident doing the case with the Chairman of Orthopedic Surgery told me the case would take “about an hour, hour and a half, tops.”  I gave the patient a little more Valium in the IV and murmured sweet nothings in his ear.  He was asleep.  All good, I started my charting.

I turned away from my charting when the patient asked what was going on.  I was annoyed, as the patient had been nicely sedated and asleep.  Nothing should be going on.  I looked over the screen to see the Chief Ortho resident putting a pneumatic tourniquet high on the thigh of my patient.  “Hey,” I said.  “You’re operating on his knee.”  The ortho resident smiled at this information.  “Orthopods hate blood,” was his response.  This was a little problem.  A pneumatic tourniquet inflated to twice my patient’s blood pressure did not feel good.  While it was within the region of my block, it was much closer than I had anticipated.  I dialed the OR table to trendelenburg (head down) position, hoping that I could get the local anesthetic bathing the patient’s spinal cord to drift a little more upstream, giving him a higher level of numbness.  This only works for a few minutes after the spinal was placed, however, so I wasn’t feeling terribly confident at this point.  And I couldn’t recheck the level of anesthesia, because now the nurse was starting to prep the patient’s leg with antibacterial solution.  Just to be safe, I elected to give the patient more Valium.  And some intravenous morphine, too.  Just in case.  Back to charting as the patient began to snore.

The case began uneventfully.  The patient snored peacefully through the initial incision and exposure, my spinal having achieved a nice, dense block.  The chief ortho resident, like all chief ortho residents at institutions of great learning such as this one, was brilliant and highly skilled.  I watched over the sterile drapes as the chief resident put down his instruments and started to do nothing.

“I’m pretty sure you’re supposed to fix it, too.  That’s what it said on the consent, you know,” I said to the ortho chief.  Ortho chief smiled at me.  “Gotta wait for The Big Man.  That’s his job,” ortho chief replied.  I looked at my watch.  One hour into the case.  I looked at the upside down face of my linebacker patient.  He was smiling through a nice, drug-induced dream.  I shrugged and went back to charting.  Half an hour later, the Chairman of Orthopedic Surgery had still not arrived.  “Call him,”  I told the ortho chief resident.  “Yeah, right,” was his response.  “How long once he gets here?” I asked, looking at my watch.  ‘Hour and a half, tops, the guy had said. I began thinking that I might have to switch to a general anesthetic if this went on too long.  For that, I would have to call in my attending to let him know what I was doing.  That would be embarrassing.  I existed on the technique of staying inconspicuous.  If I called in my attending, I would have to explain that I had miscalculated the dose on the spinal.  Embarrassing.  “Once he gets here?  Not long,” ortho resident said.  He went back to doing nothing.  My patient chortled.

Chairman of Orthopedic Surgery swept into the room ten minutes later.  Finally, I thought.  I checked the patient.  He seemed comfortable, though his heart rate was up a bit.  More Valium.  A touch more narcotic.  I looked over the drapes.  Chairman of Orthopedic Surgery was still not scrubbed in.  “Where’d he go?” I asked.  Ortho resident shrugged.  Ten minutes later, Chairman of Orthopedic Surgery, gray haired and dashingly handsome, re-entered the OR, hands held up and dripping.  “Let’s get this man back on the field!” he boomed.  “Go Yellow!”  I rolled my eyes.  Finally, I murmured under my breath.

“It hurts,” my patient said.  I looked down.  His eyes were open.  “My leg hurts,” he said.  I looked over the screen.  Chairman of Orthopedic Surgery was finally thinking about maybe doing some surgery.  I looked at my watch.  Ninety minutes of tourniquet time.  Ouch.  “No problem,” I told the patient.  I infused narcotics. More Valium.  His eyes closed.  This was going to be close.  “Not long once he gets here,” the resident had said.  Just in case, I started drawing up drugs for a general anesthetic.  Just in case.

The patient murmured something unintelligible.  His heart rate was up.  His eyes were closed.  “What did you say?” I asked softly, mouth close to his ear.  “Fucking son-of-a-bitch,” he murmured softly.  Oh, that’s what you said. I gave more Valium.  I looked over the drape.  Chairman of Orthopedic Surgery was chatting up the scrub nurse as he slowly repaired linebacker ligaments.  I made a hurry-up gesture to ortho resident.  He smiled and shrugged sheepishly.

That’s it, I thought.  Embarrassing or not, I better call my attending and switch to general anesthesia.  It wasn’t my fault that the Chairman of Orthopedic Surgery was a molasses-slow, late-arriving horse’s ass.  We were over two hours on my spinal.  No way I had any anesthetic left at the level of the tourniquet.  We were on borrowed time.  I started to turn around to use the phone to call in my attending.

Now every anesthesiologist (and anesthetist, okay?) knows that there is a perfect plane of sedation that you don’t ever want your patient to achieve.  It is that level of sedation where the patient is confused and completely disinhibited, but not asleep.  If this were Top Gun, and I was a taller version of Tom Cruise, the Maverick of brash anesthesiologists in training, it is at this exact moment that the soundtrack switches to a very loud rendition of “Danger Zone.”  As I dialed the phone with my back to my patient, I heard the sound of Velcro arm restraints being ripped in two.  Then I heard my patient say, very loudly, “FUCKING SON OF A BITCH.”  I turned back to see my very large, linebacker patient sitting bolt upright on the OR table.  He had ripped down the drapes between us and the operating field.  The patient stared at his open knee.  He repeated “FUCKING SON OF A BITCH.”  The Chairman of Orthopedic Surgery, the ortho chief resident, the scrub nurse, and the medical student hoping to some day become an orthopedic surgeon, all stared back at the patient, incredulous.  In the words which would later be stolen by Goose in that classic movie, I said, “This is not good.”

I grabbed the full syringe of Surital that I had just drawn up in anticipation of having to induce general anesthesia.  A “stick” of Surital, a short-acting barbiturate, was our general anesthetic induction of choice in those days.  I rapidly pushed the whole stick into the patient’s IV.  He flopped back with a thud onto his pillow, deeply unconcious.  I readjusted the sterile drapes to once again separate my world from the sterile operating field.  I infused a muscle relaxant into the patient’s IV and proceeded to intubate the patient and connect him to the ventilator.  There was complete silence in the OR.

The Chairman of Orthopedic Surgery broke the silence.  “What the FUCK was that?” he asked.  I returned to charting my new anesthetic technique.  Not a good time to call my attending just yet.  “You there,” the Chairman of Orthopedic Surgery bellowed.  “Behind the drapes!”  I stood up.  “Yes, sir?”  “What the FUCK was that?” he repeated.  “What?”  I asked.  He looked at me, astonished.  “What?  What, what?  That!”  he said, pointing at me, then down at the patient.  “Not sure what you mean,” I said.  The Chairman of Orthopedic Surgery looked around at the others scrubbed at the OR table.  “Didn’t you guys see that?” he asked.  Ortho resident shrugged.  Med student nodded.  Scrub nurse chose to straighten the instruments on her back table.  This just made the Chairman of Orthopedic Surgery a bit more pissed off.  He strode over to the wall and mashed the bright red code blue button on the wall with his bloody, gloved hand.  No less than five attending anesthesiologists came crashing through the door.

“WHAT?”  “What’s going on?”  “What’s wrong?”  “Is it a code?”  “Aarhgh?”  They each said, surrounding me.  I shrugged and pointed to the Chairman of Orthopedic Surgery.  Two nurses rolled the code cart into the room.  More anesthesia attendings and residents entered.  Everyone looked around.  Everything looked okay.  The patient was asleep, under anesthesia.  The ventilator sighed assuringly.  The monitors beeped happily.  I reapplied the Velcro arm restraints and said nothing.  The anesthesia attendings turned to the Chairman of Orthopedic Surgery.  “What’s wrong?” the senior anesthesia attending, my attending, asked him.  The Chairman of Orthopedic Surgery stammered, “The patient, he was awake, he screamed at me, he called me a fucking son-of-a-bitch!”  The anesthesia attendings all turned to me.  “I had to switch to a general.  The tourniquet time is over two hours.”  I raised my eyebrows significantly and rolled my eyes toward the Chairman of Orthopedic Surgery.  “We had to wait over a half hour for What’s His Name, here.”  The Chairman of Orthopedic Surgery began to turn bright red.  “Do you know who I am?” he seethed at me.  I shrugged.  Went back to charting.  My attending stepped over and began to assess the patient.  Everyone else drifted out, shaking their heads.  The code cart was withdrawn.  My attending went over my anesthesia record, which was perfect, by he way.  I loved charting.  It made everything look so neat.

The Chairman of Orthopedic Surgery was still seething, arms crossed.  “Well?” he demanded of my attending.  My attending straightened up from the chart and looked at the Chairman of Orthopedic Surgery.  “You’re pretty long on the tourniquet, Bill.  Maybe you should try to finish up?” my attending said.

“That’s it?” the Chairman of Orthopedic Surgery asked.  “That’s all you’re going to say?”

“Yeah,” my attending said.  “And now I’m leaving.”  He turned to me before he left.  “Give me a call if you need a break, Geller.”  He winked at me.