Anesthesia is Hard-3

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.

 

 

Never Say Oops in the OR

 

As a first year surgery resident, you don’t get to do much operating.  Mostly minor procedures and the simplest OR cases, especially the ones the more senior residents have no interest in, like removing skin lesions or biopsies, that sort of thing.  One of the most common surgical procedures left for the first year residents was the insertion of the chronic indwelling venous access catheter, an implanted device to facilitate infusion of medications, long term antibiotic therapy, or long term IV nutrition.Minolta DSC

This was not only a straightforward procedure, it was a very common procedure at the main University hospital we trained at.  Our service performed this operation over a dozen times a week.  As such, it wasn’t long before even the first year residents felt comfortable in the procedure.  And as first year surgical residents, it wasn’t much longer before we were feeling pretty cocky about our skill in performing this seemingly straightforward procedure.  Of course, as first year residents we had not yet internalized one of the most important tenets of all surgery:  There are no small operations.  Even the most routine procedure, the most mundane biopsy, can go horribly wrong if not approached with the respect deserved by every patient.

Towards the latter part of our first year, the residents spontaneously devised a kind of competition.  As we got really experienced in the procedure, it got to the point where we could  comfortably complete the operation in less than fifteen minutes.  When it went well, that is, which was about 95% of the time.  A couple of us were so “good” that we could occasionally complete the entire operation in about seven minutes.  So an informal competition started up amongst the first years, a hypercompetitive lot by nature, to see who could complete the operation the fastest.  It got to the point where the real objective of the resident was to have the catheter in and be suturing the closure before the attending finished scrubbing, so you could tell him when he walked in not to bother gowning up.  Attendings loved not bothering to gown up.  More time for coffee and chatting up the nurses.

It’s not hard to see where this is going.  The operation of inserting a chronic venous access catheter has nine distinct steps for its successful completion.  I know this, because as we first year residents began operating faster and faster, we managed to screw up each and every one of them.  As was the tradition in our residency program, every time a new screw-up was committed, it was named for its original perpetrator.  My class was instrumental in naming every possible screw-up related to chronic venous catheter insertion.  For the decades that followed our completion of the program, an errant first year resident could be heard being admonished by his attending not to “pull a Geller” or any one of the numerous other maneuvers we invented.  (A complete list of all the named maneuvers is available upon request, but I must pause here just to mention the Schwarma maneuver, in which the very last stitch at the conclusion of the operation is deftly passed right through the catheter, necessitating starting the procedure all over from the beginning.  Schwarma was asked to leave our program after his first year and went on to father many children during his career as a cruise ship physician.)

Step one of the procedure involved introducing a long, large-bore needle into the subclavian vein, a very large vein (about as thick as your little finger) that lies just under the clavicle (collarbone) in the upper chest as it carries blood back from the arm to the heart.  Unfortunately, this was a blind procedure in those days, made a bit more challenging by the fact that the subclavian artery, a large pulsatile structure carrying the entire blood supply to the arm, lies immediately adjacent to the target vein.  And the lung, an organ that really doesn’t like being stabbed by needles as it tends to collapse like a punctured balloon, is located immediately behind the target vein.  Inadvertent puncture of each of these anatomic structures had been accomplished thousands of times by countless surgical residents for decades.  We, therefore, were already trained in the precautions necessary to avoid these structures.  We were much more creative.

As I said, back in those dark old days of my training, this was a “blind stick.” (Currently, technology has progressed to allow real time ultrasound guidance of the procedure.) As a blind procedure, the surgeon is reassured that he had struck the correct anatomic structure with his needle by seeing the gentle return of dark red, venous-type blood from the hub of the needle when the syringe was disconnected.  It was appropriate, however, to quickly cover the hub of the needle with your finger so as to prevent air from being  sucked into the low pressure venous system.  This is called an air embolism and can immediately lead to a cardiac arrest or stroke.  This was to be avoided, having already been done many times as well.  One afternoon, towards the end of our first year, one of my first year colleagues named Dr. Sweetness was performing this procedure, smoothly and confidently proceeding before his attending came in the room.  Actually, he had begun before his attending was even in the operating suite, not that unusual at the time but a sign of cockiness for a first year resident.  Sweetness was pretty cocky at this point, as were we all.  Dr. Sweetness inserted the needle and was immediately rewarded with a flash of blood.  Rather than carefully consider the nature of the blood return, however, he immediately assumed it to be venous and clamped his finger over the hub of the needle.   Like I said, he was moving pretty fast.

Step two of the procedure is to insert a flexible  guide wire through the needle into the patient’s venous circulation, actually passing the wire near the chambers of the heart.  I should digress at this point to mention that it is important not to insert the entire wire into the vein, but rather to hold onto its end.  My fellow resident, Dr. Napoleon, failed on one occasion to follow this simple rule.  He neglected to maintain control of the end of the guide wire, which he smoothly and accidentally introduced completely into the patient’s vein, where it proceeded to pass downstream into the heart and lodge there.  This trick, thereafter known as the Napoleon maneuver, necessitates immediate abandonment of the planned operation and stat consultation with a cardiologist for percutaneous fluoroscopically guided extraction of the rogue guide wire.  This also required a very embarrassing conversation with the patient and his family, a conversation that never failed to upset the attending surgeon.

But I digress.  Sweetness smoothly introduced the guide wire and maintained control of its end throughout.  He did not, however, appreciate the fact that he had introduced the guide wire into the subclavian artery, not the vein.  In and of itself, this would not be remarkable, for as I mentioned, this particular maneuver had been done literally thousands of times.  Usually, however, the operator was immediately aware of the error when, upon removing the syringe from the end of the needle, bright red blood (not deep purple as it should be) sprayed like a fire hose into your face.  At that point, the surgeon need only fight the urge to curse or say “Oops”  (“Never say ‘Oops’ in the OR”) and remove the needle from the wrong vessel, then to hold pressure until the body’s natural tendency to recover from our screwups takes effect.  No permanent harm, no foul, as they say.  Unless, of course, you don’t realize what you’ve done.

This particular patient also had the unfortunate combination of low oxygen saturation in his blood stream and low blood pressure introduced by the inexpertly administered anesthetic provided by the first year anesthesia resident.  Therefore,  Sweetness didn’t realize he was in the artery.  Not just in the artery, though.  As luck would have it, Sweetness had managed to enter the subclavian artery extremely close to its takeoff from the aorta.  You know the aorta, the single largest blood vessel in the human body that carries the entire output of blood from the heart.  It tends to bleed very vigorously and fatally when injured.

Now, even that would probably have been kind of okay, if Sweetness at any point realized what was going on.  But this was a blind procedure, the usual cues had been taken away by his equally youthful anesthesia colleague, and Sweetness smoothly and confidently proceeded; still with no attending in sight.  Step three of the procedure is to gently and smoothly pass a dilating catheter over the guide wire, called an introducer.  The introducer is a gracefully tapering, somewhat flexible plastic straw that serves the function of gently stretching a hole in the wall of the blood vessel so that the catheter can be introduced.  I say ‘somewhat flexible’ because it is actually quite stiff–it has to be to perform its function.  It is, therefore, necessary to introduce this device with some degree of trepidation and finesse.  Sweetness had the finesse part down pat–it was the trepidation that was missing at this point.  Sweetness smoothly and expertly passed the introducer over the guide wire, a maneuver that he had performed without incident almost a hundred times before.  On this occasion, however, through a combination of bad luck, rushed technique, and inexpert assistance on the part of his anesthesia colleague, passage of the stiff-walled introducer device caused the root of the subclavian artery to be torn from its origin on the aorta.  This, of course, resulted in a large tear in the aorta.  The patient, already quite ill, proceeded to hemorrhage massively into his chest cavity.  The attending surgeon walked into the operating room just in time to see his patient, supposedly there to undergo a relatively minor procedure, receiving CPR on the OR table.

Oops.

Equanimity

In surgery, as in many fields of endeavor, it is never a good idea to panic.  We strive for equanimity, the ability to remain calm and effective despite surprising or difficult circumstances.  We never curse or say “Oops” after cutting the wrong structure or getting sprayed in the face by an unanticipated fountain of blood, for instance.  The well trained surgeon merely says, “Well, that’s interesting,” or something similar.  (Anesthesiologists know that when the surgeon says that something is interesting, it’s time to start transfusing blood pretty rapidly.)  This particular personality trait was drilled into me throughout my surgical training, but never so effectively as by my senior resident and mentor, Ben Jeffries.  Ben at the time was new to our program, having been tossed out of the Johns Hopkins surgery residency as part of the pyramid system they use and because he wasn’t a dick.  You gotta be a dick if you’re going to succeed in the Hopkins surgery program.  Fact.  Anyway, Ben was a skilled surgeon and a positive influence in our program after he joined us in his third year of training.  We still stay in touch.IMG_1154

A lot of what we do in surgery is done because that’s the way we do it.  Of course, what we do is based upon careful scientific research.  How we do it, however, is often done because we do it that way.  Not always the best way, as it turns out.

The surgical procedure of tracheostomy is frequently performed upon critically ill patients in the intensive care unit who require long term support on a ventilator.  It is dangerous and uncomfortable to maintain a breathing tube down the patient’s throat for longer than a week or two, so the patient is eventually scheduled to undergo the routine procedure of making a surgical opening in the windpipe, the trachea, and inserting a special tracheostomy tube.  This tube is much more comfortable for the patient and is less prone to becoming blocked or dislodged.  Research has proven over and over again that it is a valuable surgical procedure.

Research has not clearly addressed just how this valuable procedure is to be accomplished, however.  A couple of options are available to the surgeon about to embark upon the procedure of tracheostomy.  The safest and most enjoyable manner for all concerned, surgeon and patient, is to perform the tracheostomy in the operating room.  Everything is more fun in the OR.  In the OR, the surgeon is surrounded by skilled, helpful personnel, a trained anesthesiologist is carefully managing the critically ill patient’s respirations and sedation, the lighting is optimal, and every tool one can possibly need is readily available.  So, of course, we often don’t do tracheostomies in the OR.  We frequently perform this surgical procedure in the patient’s bed in the ICU.  This is much more efficient–which means, it’s much cheaper.  Can’t honestly think of any other reason.

As part of my surgical training, I rotated through a very busy community hospital.  This hospital had a large, pleasant Pulmonary Intensive Care Unit, the PICU, which cared for patients who required ventilator support because of emphysema, lung surgery, or other severe pulmonary illness.  These patients often required tracheostomy.  On this occasion, I was a second year resident, having been a doctor for about eighteen months.  My service was consulted to perform a “trach” on an elderly, robust man who had been requiring high levels of ventilator support for over a month.  He was overdue for the procedure and our attending, an ebullient thoracic surgeon named “Tex” Dallas, felt we should get this done ASAP.  Tex was a skilled, flamboyant thoracic surgeon, who had the practice of wearing a cowboy hat while doing hospital rounds.  Nobody knew why he had to leave Texas, but he cut a loud and colorful swath through the Midwestern surgical society while he was here.  Tex told Ben, my senior resident, to get the trach done “today” in the PICU and he’d staff the procedure.  Which meant that Tex would be flirting with the PICU nurses (one of which would go on to become a skilled physician and my wife) while we did the procedure at the bedside.

Ben and I prepared the patient for his tracheostomy by setting up the instruments that we borrowed from the OR.  We recruited the Respiratory Therapist to help, as there comes a point in the operation when the tube already in the trachea and supporting the patient’s respirations, called the endotracheal tube, needs to be removed from the patient’s mouth so that the surgeon can put in the new tracheostomy tube.  This role is usually filled by a trained anesthesiologist or anesthetist in the OR, of course.  We, as I mentioned, weren’t in the OR.  But the Respiratory Therapist was enthusiastic and anxious to help, especially since she’d never seen this done before.  Ben and I instructed her on when and how we’d like her to remove the tube when we said so.  She nodded enthusiastically.  This was exciting.

Ben and I got started.  The patient was cooperative as we had given him a small dose of sedative, his breathing being entirely supported by the ventilator anyway.  The operation started well, with Ben letting me do everything while he held the tissue out of the way with retractors.  This was critical, as the patient had a bull like neck and the hole to reach his trachea was therefore deep and narrow.  And since we weren’t in the OR with all the special lighting, a little dark, as well.  Tex was sitting at the nursing station, which was around the corner from where we were working, watching the patient’s vitals on the monitor and trying to convince the stunningly beautiful nurse to join him at lunch after the procedure.  (Did I mention that I married the woman about a year later?)  The operation was going smoothly and we had the surface of the trachea cleanly exposed in the depths of the wound.  Ben turned to the Respiratory Therapist standing at the patient’s head, watching with fascination.  “Ready to remove the tube?” he asked her.  She nodded enthusiastically.

At this point, it is necessary to carefully cut into the trachea and create a small window in which to insert the new tube.  As I began this maneuver, Ben suggested that I take care to avoid the small blood vessel just adjacent to the point we had picked for our window.  While it wasn’t a conscious decision (in the dark depths of the wound I couldn’t see from my angle what he was referring to), I ignored his advice and instead severed the vessel just as I cut into the windpipe.  The wound immediately filled with blood.  “That’s interesting,” Ben said.  I was speechless.  “Okay, it’s out,” the Respiratory Therapist said.  We both turned to look at her.  She was smiling as she displayed the endotracheal tube she had removed from the patient.  “Really?” was all Ben said.

Ben and I bravely suctioned and retracted in our efforts to expose the trachea so that we could get a tube into the patient.  At this point, the patient was not receiving any oxygen or any type of respiratory support.  He had, at best, a couple of minutes to live unless he was reconnected to the ventilator.  The blood welling up from the wound became progressively darker as we struggled.  Listening to the EKG monitor, we could hear the patient’s heart rate slowing as he lost oxygenation.

“You boys okay back there?” Tex called from around the corner, watching the pulse slow on the monitor at the nurse’s station.

“Just fine, Dr. Dallas,” Ben called back.  We were not fine.  We were completely fucked, actually.  The wound was so deep that we needed two hands to hold the tissue out of the way, leaving only two hands to suction the bleeding and operate–about two hands short of what we needed.  We couldn’t see shit.  The patient was rapidly deteriorating.  The Respiratory Therapist was looking over, fascinated.  “That’s a lot of blood,” she commented helpfully.  The patient’s heart rate continued to slow.

“Boys?” Tex called from the desk.

The patient’s heart stopped.  He was in arrest.  I looked up at the monitor.  Flatline.  Ben took the tracheostomy tube from me and jabbed it blindly into the wound.  “Ho-ly Shit!” we heard Tex shout from around the corner.  Ben hooked the tube up to the ventilator, having no idea whether the tube was actually in.  It must have been in place, however, because in the next few seconds the patient’s heartbeat reappeared and quickly came up to normal.  Tex came skittering around the corner and pulled up short at the foot of the bed, looking at the monitor.

“That’s pretty weird,” Tex said, scratching his head.  “Poor bastard was looking a little dead there for a bit.  That monitor must be fucked up.  You boys all good here?”

“No problem,” Ben said.  “All good.”

Tex bent down to pick up his hat that had flown off as he ran around the corner.  As he bent down, he noticed the half-inch deep puddle of blood under the bed and lapping at our shoes.

He straightened up, smiling.  “Nice job, boys, nice job.  Now don’t make that pretty young nurse have to clean up after you boys now, you hear?”

“Of course not, Dr. Dallas.  We’re better than that.”  Ben smiled at him.

Not much better, though.

Mommas, Don’t Let Your Babies Grow Up To Be Surgeons

 

There is a reason surgeons are generally disliked by other physicians.  And a lot of other people, too.  A fair percentage of us are assholes.  While disagreeable surgeons may be easily found in every field of surgery, it is universally agreed that the biggest assholes are thoracic surgeons.  There are many reasons for this, generally relating to the type of person attracted to a program that requires every-other night call for upwards of seven years.  There are other reasons, too.IMG_0122

As a senior medical student, I considered myself hot shit.  I was smart and extremely hard working–in other words, I had no girlfriend.  As a hotshit senior medical student at an institution that considered itself to be the world’s best medical school, and destined in my mind to be a famous surgeon, I felt compelled to do an elective rotation on the thoracic surgery service at the University of X* Medical Center.  The audacity of such a move cannot be overstated.  This was undoubtedly the most demanding rotation a student could elect.  Actually, the term most often used by my predecessors was “abusive.”  My two housemates, at the time, were both performing elective radiology rotations in Hawaii.  They came back tan and able to surf.  Also, with a condition that required antibiotics and, for one of them, eventually required clandestine child support.  I never left the hospital.

The noncardiac thoracic surgery service at U of X* was run by a young, brilliant, academically-trained surgeon.  For many, many reasons, too many to go into here, he is generally regarded to be the greatest asshole the surgical world has ever known.  I spent two months on his service, rarely leaving the hospital except to change clothes.  He never learned my name.  The tone of the service was evident almost immediately.  On my first day, I was told to scrub in on a complex esophageal operation being performed by Dr. Asshole.  This didn’t faze me, as I had already completed two lengthy surgical rotations and felt at home in the OR.  In addition, I had spent the vacation time prior to this rotation reading everything I could about thoracic surgery, esophageal surgery, and Dr. A’s publications–all of them.  I told you, I was hot shit–and had no girlfriend.  Anyway, I scrubbed in and introduced myself to silent nods all around.  Dr. A seemed at ease, bantering with the Chief Thoracic Surgical Fellow as the operation proceeded smoothly.  I was familiar with the procedure from my readings and quite knowledgeable regarding the controversies surrounding it, as well as Dr. A’s writings on the subject.  As the majority of the operation was accomplished and the chest was being closed, I gently but professionally asked Dr. A a question; an insightful, sincere, and well-meaning question.  The question was greeted by complete, cold silence.  During this silence, Dr. A stopped working, carefully put down his instruments, and looked me straight in the eyes.  “Who are you?” he  finally asked.  I reintroduced myself, it having been a full forty minutes since I last told him who I was.  At this, he gently shook his head, picked up his instruments, and went back to helping close the chest.  During the subsequent eight weeks of working with him, he never said another word to me.  Great guy.

During this rotation I became good friends with the Chief Thoracic Surgical Fellow (CTSF), a very decent individual, married with two kids, who spent every single moment for two years in the hospital.  Every few days his wife brought his kids over so that they could all have dinner together and the children reminded that their mom really wasn’t a single parent, meeting them lovingly in the hospital cafeteria.  She also brought him clean clothes for office hours and conferences–every other moment he was dressed in scrubs.  He was a great teacher and mentor.  About three or four weeks into the rotation, I was scrubbing with the CTSF, getting ready for a very interesting procedure, a transthoracic Collis-Nissen antireflux procedure.  It was one of Dr. Asshole’s specialties and he did a lot of them, patients coming from literally all over the world to have him perform the operation.  Usually, Dr. A would appear about thirty or forty minutes into the operation, allowing time for the CTSF to get the patient positioned and the chest opened with the Senior Surgical Resident currently rotating on the service.  On this day, however, Dr. A suddenly appeared and started scrubbing with us.  He was in an exceptionally good mood, joking with the residents (and, of course, completely ignoring me).  Just before we’re all ready to quit the sink and head for the OR, Dr. A turns to the CTSF and asks, “So Paul, how long?”

“I’m not betting,” Paul, the CTSF, replies.

“You have to bet, Paul,” Dr. A responds.

“I don’t think it’s right, Dr. Asshole.  I can’t bet you.”

“If you don’t bet, Paul, you might as well scrub out because I’m gonna do the whole goddammed case with whoever this asshole is, then.  You won’t touch the knife.  So, how long?”

The CTSF shrugs, “Fine.  Thirty minutes.”

“Great, thirty minutes, twenty bucks.”  And Dr. A sweeps into the Operating Room.

“What was that?” I ask the CTSF

“Shut up.”  He followed Dr. A into the OR, and I followed him.

Dr. A, as Chief of the Division of Thoracic Surgery and a very busy surgeon, had his own operating room with a dedicated team of nurses and technicians.  He had been at The World’s Best Medical Center for almost a decade and his team was exceptional.  As a testament to their experience and competence, whole procedures would often be accomplished without the surgeon ever asking for an instrument.  He would put out his hand and Stella, the scrub nurse, invariably slapped the exact right instrument into his palm without the great man’s eyes ever leaving the operating field.  In two months, I never saw her give him anything except the exact right instrument without so much as a fraction of a second’s hesitation.  Stella was a middle aged African-American woman, tall and soft spoken, who scrubbed on all of Dr. Asshole’s procedures.  The two circulating nurses on the team were just as dedicated and competent.  Every operation was like a beautifully choreographed ballet.  And there was never any doubt in the room about who was the principal dancer, maestro, and sovereign authority.

On this day, however, it was immediately apparent that something was up.  As Dr. A dried his hands, he asked Stella how she was doing, and made small talk about her family.  “Just fine, Dr. Asshole, thanks for asking,” Stella replied, smiling.  I’d never seen him so personable.  Maybe my impression of him as the world’s biggest prick wasn’t completely accurate, I remember thinking.  “Everybody all set?” Dr. Asshole asked jauntily.  Everybody enthused their affirmatives, and the CTSF made the incision.

The operation was going great,  Dr. Asshole was letting the CTSF do most of the work and Paul was an extraordinarily skilled operator. Dr. Asshole was actually complimenting him on his technique.  About twenty minutes into the operation, Dr. Asshole, in a completely nonchalant tone and without looking up, asks Stella for a curved Satinsky clamp.  Immediately, Stella shot a glance at the circulating nurse.  The circulating nurse bolted for the door.  Dr. Asshole still had his hand out.

“Dr. Asshole, that clamp is not on my field.  I’ll have it for you in sixty seconds,” Stella stated calmly, though I could tell she had blanched above her mask.  “Is there another clamp that will suffice?”

Dr. Asshole stood up straight and looked aghast.  “You don’t have the Satinsky?” he asked, incredulous.

“Dr. Asshole, we’ve done this operation together over one hundred times.  You have never asked for the Satinsky before.  That clamp is not on the tray.  I’ll have it for you in  thirty seconds,” she responded smoothly.  She was right, of course.  I had, myself, scrubbed with him twice earlier in the week on the exact same procedure and he hadn’t asked for the clamp in question. I had no idea what was going on.

“My God, woman!” Dr. Asshole suddenly shouted.  “How the Hell am I supposed to do this operation without a goddammed clamp? Huh?”

“Is there another clamp I can give you, Dr. Asshole?”

Dr. Asshole reached over onto her tray of instruments, something that I’d never seen any well-trained surgeon do before.  The scrub nurse’s Mayo stand was her territory and sacrosanct.  It was almost as if Stella had reached over into the wound to pinch the heart.

“Just give me a fucking clamp,” he growled.  As he grabbed a clamp off of the tray in front of Stella, he knocked about twenty carefully arranged instruments crashing to the floor.  Stella’s eyes were wide above her mask, but she said nothing.  Dr. Asshole began to roughly dissect in the patient’s chest cavity with a long right angle clamp he had grabbed from in front of her.  At  this moment, the OR door burst open and the circulating nurse skittered in, breathless.  She smoothly delivered the Satinsky clamp onto Stella’s back table with the practiced motion of a professional baseball pitcher.  Stella smoothly proffered the clamp.  “I have the Satinsky, Dr. Asshole,” she said flatly.

But at this point Dr. Asshole was loudly cursing into the wound as he roughly dissected in the chest.  Dark blood began to well out of the chest cavity.  Paul had become a statue.  He looked like he was in pain.

“Look at this, Stella,” Dr. Asshole nearly screamed.  “Now he’s bleeding, he’s goddammed bleeding because you don’t have the tools I need to do this operation.  This guy’s gonna bleed out because you didn’t think to have the tools we need.”

“I have the clamp now, Dr. Asshole,” Stella repeated.

“Too late, goddammit,” Dr. A snarled.  He grabbed the clamp from her and hurled it across the room, just missing the circulating nurse.  It clanged off the wall behind her.

Stella looked stricken.  There was a brief moment of silence as we all looked at the merlot colored blood welling up from the chest cavity.  Suddenly, Stella burst into tears.  She muttered something apologetic about having to step out for a moment.  She ran from the room, still gowned and gloved.

The operating room was stone silent.  Dr. Asshole looked at the clock, then at Paul standing on the other side of the OR table.

“Twenty-four minutes.  You owe me twenty bucks, buddy.”