Tag Archives: nurse anesthetist

Anesthesia is Hard-3

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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.Top Gun

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.

 

 

(CRNA)nesthesia isn’t Easy-2

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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.Tinc of Cocaine

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.”

 

 

Lub Dub

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During my Chief Residency (fifth and last) year of surgical training, I was working at the large academic hospital for a three month rotation.  During this rotation, I was in charge of a general surgery service with an emphasis on oncology surgery.  This was a plum rotation for the chief, for we got to perform large operations just about all day, every day.Minolta DSC

While finishing a particularly satisfying distal pancreatectomy with my attending, my junior resident came into the OR, excused himself for interrupting, and told me that he had received a request for a consultation in the Medical ICU to “rule out acute abdomen.”  This phrase, when voiced by any member of the Medical ICU resident staff, uniformly portended disaster.  I instructed him to find the third year resident on our team and for them to go check things out.  I went back to closing with the help of the intern while my attending broke scrub to do whatever attendings did between cases.  Once closed, I left instructions for the intern to write postop orders and, donning white lab coat, took the elevator up to the MICU to check out the consult.

My residents were at the bedside of the patient in question and explained that, as expected, the gentleman was an elderly, sick-as-shit individual,  currently hanging onto the merest shade of life with the help of infusions of every medication the medical intensivists had available.  It was also obvious, from a cursory review of the patient’s medical record, that he had begun the process of dying almost ten days earlier due to impaired blood flow to his bowel.  Though that diagnostic possibility had eluded the medical intensivists, today the rather clear-cut evidence of full blown gangrene of the bowel had pushed them to think fondly of their surgical colleagues for assistance.  Almost any internist will call a surgical consult when the patient is screaming at the top of his lungs about how much his belly hurts.  Of course, the initial reaction to this event had been for the internists to promptly sedate, paralyze, and intubate the individual, six days ago.  Connecting the patient to a ventilator always makes the screaming stop.  Now that the patient had deteriorated to the point of imminent demise, and it was impossible to examine the patient or take a medical history, they had called the consult.

Though unable to perform at this point a meaningful bedside exam, my residents had reviewed the laboratory tests of the past several days, about eighty of which clearly indicated progressive gangrene of the bowel.  They had also reviewed the three CT scans which had been obtained during the past eight days, each documenting the clear progression of gangrenous changes of the bowel.  They also reviewed the medical student’s ICU admission note, cosigned but undoubtedly unread, that listed as number 14 on the differential diagnosis list “Ischemic gangrene of the bowel.”   My third year resident had circled that, written “You think?” next to it with a smiley face.  I instructed my team to get a consent for surgery from some family member and have him down in the OR after my next case.  I told them that if they didn’t screw this up, I’d staff the two of them on it and let my fellow Chief do the last case in my room  He’d be thrilled and they were thrilled at the prospect of doing a real operation.

Two hours later, I was finishing my next case when the intern came in to tell me the consult patient was in OR 7, being prepped by anesthesia.  I said great, good work, I’ll be right over.

I came into the OR just behind an EKG machine being wheeled in by the circulating nurse.  Mr. Really Sick MICU guy is on the OR table with an anesthesia attending and two anesthesia residents buzzing around him.  There’s a nurse anesthetist who looks about sixteen years old sitting at the head, working the controls.  I stand in the door as I watch one of the residents start to hook up the new EKG machine, a most unusual thing to do.

“What’s up?” I ask innocently, to no one in particular.

“EKG’s screwed up,” Anesthesia Resident Number One replies.

“Unusual,” I comment sagely.

“Happens,” he replies, supersagely.

“Is his pressure okay?” I ask.

“Can’t get a pressure off the cuff, too edematous,” Anesthesia Resident Number Two informs me.

“Hmmm,” I reply.  ‘How about the a-line?” I inquire, pointing at the monitor.

“Waveform’s damped, haven’t been able to flush it.  Probably kinked,” Number One again.

“Hmmmmm,” I reply.  I approach the patient and can’t help but notice that the second EKG tracing is not very impressive either.  I gently palpate the patient’s groin for a pulse.  Nothing.

“Excuse me,” I say to the nurse anesthetist, who is listening to the patient through an esophageal stethoscope.  She looks up and pulls the earpiece out to listen to me.  “Excuse me, but do you hear lub, dub?”

“What?” she asks smiling, pleasantly confused by my question.

“Do you hear lub dub, lub dub?  You know, like a heartbeat?”

“Actually, no,” she responds rather sheepishly, “Good breath sounds, though”–more brightly.

“Okay,” I announce loudly, making a show of looking at my watch, “I’m pronouncing at 3:42.  He’s dead.”  All motion stops.  Awkward silence.  Anesthesia attending sputters to life–“What are you talking about?”

“He’s dead,” I deadpan.

“What do you mean?”

“I mean that you have been giving anesthesia to a dead person for–how long have you been in the room?” to the circulating nurse.

“Twenty minutes or so,” she answers.

“Twenty minutes or so,” I conclude.  I smile.  I really shouldn’t have smiled.

Anesthesia attending goes ballistic.  “Call a code!” he yells as he starts to pull all the covers off the patient.  “Start CPR!” to Residents One and Two.  All hell starts to break loose.  “Get a code cart in here!”  Multiple anesthesia attendings and residents begin to flood in through various doors.

“Hey, come on,” I beseech, fairly loudly over the din.  “He’s been dead for almost half an hour–you’re going to start coding him now?”  Awkward silence re-ensues.  “3:42.  Dead.  Elliot–” to my third year, “call the next of kin.  See if you can get an autopsy.”  And I’m outta there, stealing back my case from my fellow chief resident.

Surprisingly, it takes a full two days before I’m told the Chairman wants to see me.  “You wanted to see me, Dr. W*?”

“Yes, Evan.  How are you?  How’s your lovely wife, Sheri?

“Great, thanks.  How’s yours?

“Great, thank you for asking.”  I’m looking at a report on his desk.  Upside down I can make out (all capitals) LUB DUB. Underlined twice, with quotes.   “Say, Evan, just wanted to speak with you about a note I received from the Chairman of Anesthesia.  You might remember a case from a couple of days ago…”