Every now and then, when it is my turn to be the doctor in charge of coordinating anesthesia efforts in our 35+ operating room system, I recieve a page from one of my partners.
Typically it's one of my middle-aged male partners, who, after drinking their morning cups of joe (an absolute requirement for anesthesiologists), and never being able to fully empty their bladders due to aged-induced benign prostatic hypertrophy, begin calling at about 9:15 AM. This is a predictable scenario; it happens every day. And it's very easy to deal with. I just stand at the head of the bed and chat up the surgeon for a couple of minutes. Usually the surgeon has a thing or two to say about how it seems that my partner isn't quite old enough for prostate issues and how he must just have a weak consititution, and how common that is amongst anesthesologists. Thick skin is also a requirement. The gas doc returns happy and thankful.
The second most likely scenario is a call from a partner who was running late that morning and didn't have time for that 1st, 2nd or 3rd cup of coffee, that one cup that is required to relieve head tension and to focus concentration. This is also easy to deal with. Stand at the head of the bed and chat up the surgeon. The surgeon usually has a comment about how easy our jobs must be that we can take coffee breaks whenever we want. Again, the gas doc returns relieved and thankful.
And then sometimes, not very often, but sometimes, I recieve a call from a partner asking me to come and help them with an airway. I can immediately sense a difference in the tone of their voice. Typically, they try to act casual and calm. That is how we must act to maintain a sense of order in the room during difficult airway scenarios. But I can usually hear an edge that most people wouldn't be able to discern. All anesthesiologists can hear this edge.
Last week it was Dr. M. He said, "Um, Christy, would you have a moment to stop by room 2? I'm having a bit of trouble getting this tube it." And there it was: the edge.
I immediately dropped what I was doing. My conversation with a pre-op nurse ended, the orders I was writing were left undone, my coffee cup, unattended. And I ran-walked to OR 2. Why the hurry? Because when airways go bad, they go bad fast. And without oxygen a patient can die in minutes. And if my intelligent, skilled, board-certified anesthesiologist partner is calling me for help, then he needs help quickly.
On the table was a 72 year old woman with ovarian cancer and metastatic disease to her cervical spine. Her neck bones were so painful that she decided, despite her limited life expectancy, to have them fused. This operation would eliminate her pain.
And she was a relative of one of our anesthesia techs. The sweetest anesthesia tech in the world and babysitter extraordinaire for my children. Damn! Damn! Damn! The lady on the table had the curse! An unwritten but 100% infallable rule: there will be some sort of complication with your surgical procedure, anesthetic or hospital stay if you are a nurse, doctor, tech or related to one.
The woman on the table was an eggplant shade of purple. I could hear the ominous baritone beep of a pulse oximeter in the background. 38%. Very bad. O.K. Time to act. I helped Dr. M bag the patient up. I held the mask on her face with two hands while performing a two handed jaw thrust, as Dr. M inflated her lungs with 100% oxygen by squeezing the bag on the anesthesia circuit. Over the course of two tense minutes her sats were in the 90s. Whew. During that time Dr. M told me what he had tried, so far, to get the tube in.
Mac 3. No view. Mac 4. No view. Miller 2. No view. By this time it was likely that some mild bleeding was developing in the back of the throat from repeated laryngoscopy trauma. LMA inserted. No ventilation possible. By this point edema was probably setting in and the sats were dropping. That is when Dr. M attempted to bag the patient back up. Due to edema and secretions, he was unable to do it himself, and then called me for help.
Now, with a two-man technique, the sats were up and we needed to figure out what to do. The surgeon was sitting in the corner; a common place for surgeons during airway crises. They are deathly afraid of lost airways. Simply because they have no idea what to do but to call an anesthesiologist. And we were already there, meaning he was out of options. The surgeon suggested cancelling the operation and waking the patient up. But the paient was now stable and desperately wanted this surgery to have the chance to die in peace, whout the debilitating neck pain she had been having.
Dr. M passed a fiberoptic bronchoscope into the patients nare and tried to visualize the vocal cords directly. All he could see was blood and mucous. We passed a suction catheter. Looked again. Blood. It was accumulating as fast as we could suck it.
I asked Dr. M if he'd tried a Mcgrath laryngoscope. No. I asked the anesthesia tech to prepare one for me. It was apparent that Dr. M wanted me to lead the effort. He was exchausted and a fresh algorithm was a good idea for this patient. I placed the Mcgrath. No view. But wait. Were those tiny air bubles that I could see? Could that indicate the path to the lungs? Air bubbles being passively exhaled as I performed a largngoscopy? "Eschmann stylet please." I passed the stylet into the dark area where I had seen the air bubbles. As I passed the stylet I saw a thin white stripe to the side of the dark hole. It was a vocal cord! So close. Dr. M passed a 6.0 endotracheal tube over the stylet and I guided it into the air bubble hole under direct visualization with the Mcgrath. Balloon up, stylet out, scope out. Big breath, chest rise, positive end-tidal CO2, equal breath sounds. We're in! Thank you God.
Dr. M and I locked eyes. He said, "Thank you, Christy."
He and I both know those words, when passed from one anesthesiologist to another after such a scenario, when the life of his patient hung in true limbo, mean far more than just "thank you." It's the same two words and eye lock that I have given to many of my partners, many times. A look that only an anesthesiologist can fully understand. We usher our patients in and out of waltzes with death every day. We literally take them as close to death as they'll ever be, until they die. And we almost always bring them back effortlessly. But when we don't we are dealt a blow. A blow of grief, embarassment, self-doubt and fear. We experience nausea, insomnia, saddness. It is not easy to feel somehow responsible for the death of someone who trusted you with their life. Whose parents and children and husband trusted you, too. And for your partner to help you avoid that gut-wrenching blow instills in you tremendous gratitute. But you only say, "Thank you."
Unfortunately, this patient suffered a spinal cord injury during the procedure. Her disease-ravished crumbling vertebrae could not withstand the surgical manipulation, and she woke up a permanent, ventilator-dependent quadriplegic. A risk she understood and accepted prior to surgery. In keeping with her wishes, the family gathered in the ICU three days after her surgery. Everyone said their goodbyes. She wanted no end-of-life sedation. No morphine or valium to ease the pain and anxiety of suffocation. She wanted to be fully present in her death. Her breathing tube was removed and she died within five minutes, with her husband holding her hand.
Another day at the office.
Typically it's one of my middle-aged male partners, who, after drinking their morning cups of joe (an absolute requirement for anesthesiologists), and never being able to fully empty their bladders due to aged-induced benign prostatic hypertrophy, begin calling at about 9:15 AM. This is a predictable scenario; it happens every day. And it's very easy to deal with. I just stand at the head of the bed and chat up the surgeon for a couple of minutes. Usually the surgeon has a thing or two to say about how it seems that my partner isn't quite old enough for prostate issues and how he must just have a weak consititution, and how common that is amongst anesthesologists. Thick skin is also a requirement. The gas doc returns happy and thankful.
The second most likely scenario is a call from a partner who was running late that morning and didn't have time for that 1st, 2nd or 3rd cup of coffee, that one cup that is required to relieve head tension and to focus concentration. This is also easy to deal with. Stand at the head of the bed and chat up the surgeon. The surgeon usually has a comment about how easy our jobs must be that we can take coffee breaks whenever we want. Again, the gas doc returns relieved and thankful.
And then sometimes, not very often, but sometimes, I recieve a call from a partner asking me to come and help them with an airway. I can immediately sense a difference in the tone of their voice. Typically, they try to act casual and calm. That is how we must act to maintain a sense of order in the room during difficult airway scenarios. But I can usually hear an edge that most people wouldn't be able to discern. All anesthesiologists can hear this edge.
Last week it was Dr. M. He said, "Um, Christy, would you have a moment to stop by room 2? I'm having a bit of trouble getting this tube it." And there it was: the edge.
I immediately dropped what I was doing. My conversation with a pre-op nurse ended, the orders I was writing were left undone, my coffee cup, unattended. And I ran-walked to OR 2. Why the hurry? Because when airways go bad, they go bad fast. And without oxygen a patient can die in minutes. And if my intelligent, skilled, board-certified anesthesiologist partner is calling me for help, then he needs help quickly.
On the table was a 72 year old woman with ovarian cancer and metastatic disease to her cervical spine. Her neck bones were so painful that she decided, despite her limited life expectancy, to have them fused. This operation would eliminate her pain.
And she was a relative of one of our anesthesia techs. The sweetest anesthesia tech in the world and babysitter extraordinaire for my children. Damn! Damn! Damn! The lady on the table had the curse! An unwritten but 100% infallable rule: there will be some sort of complication with your surgical procedure, anesthetic or hospital stay if you are a nurse, doctor, tech or related to one.
The woman on the table was an eggplant shade of purple. I could hear the ominous baritone beep of a pulse oximeter in the background. 38%. Very bad. O.K. Time to act. I helped Dr. M bag the patient up. I held the mask on her face with two hands while performing a two handed jaw thrust, as Dr. M inflated her lungs with 100% oxygen by squeezing the bag on the anesthesia circuit. Over the course of two tense minutes her sats were in the 90s. Whew. During that time Dr. M told me what he had tried, so far, to get the tube in.
Mac 3. No view. Mac 4. No view. Miller 2. No view. By this time it was likely that some mild bleeding was developing in the back of the throat from repeated laryngoscopy trauma. LMA inserted. No ventilation possible. By this point edema was probably setting in and the sats were dropping. That is when Dr. M attempted to bag the patient back up. Due to edema and secretions, he was unable to do it himself, and then called me for help.
Now, with a two-man technique, the sats were up and we needed to figure out what to do. The surgeon was sitting in the corner; a common place for surgeons during airway crises. They are deathly afraid of lost airways. Simply because they have no idea what to do but to call an anesthesiologist. And we were already there, meaning he was out of options. The surgeon suggested cancelling the operation and waking the patient up. But the paient was now stable and desperately wanted this surgery to have the chance to die in peace, whout the debilitating neck pain she had been having.
Dr. M passed a fiberoptic bronchoscope into the patients nare and tried to visualize the vocal cords directly. All he could see was blood and mucous. We passed a suction catheter. Looked again. Blood. It was accumulating as fast as we could suck it.
I asked Dr. M if he'd tried a Mcgrath laryngoscope. No. I asked the anesthesia tech to prepare one for me. It was apparent that Dr. M wanted me to lead the effort. He was exchausted and a fresh algorithm was a good idea for this patient. I placed the Mcgrath. No view. But wait. Were those tiny air bubles that I could see? Could that indicate the path to the lungs? Air bubbles being passively exhaled as I performed a largngoscopy? "Eschmann stylet please." I passed the stylet into the dark area where I had seen the air bubbles. As I passed the stylet I saw a thin white stripe to the side of the dark hole. It was a vocal cord! So close. Dr. M passed a 6.0 endotracheal tube over the stylet and I guided it into the air bubble hole under direct visualization with the Mcgrath. Balloon up, stylet out, scope out. Big breath, chest rise, positive end-tidal CO2, equal breath sounds. We're in! Thank you God.
Dr. M and I locked eyes. He said, "Thank you, Christy."
He and I both know those words, when passed from one anesthesiologist to another after such a scenario, when the life of his patient hung in true limbo, mean far more than just "thank you." It's the same two words and eye lock that I have given to many of my partners, many times. A look that only an anesthesiologist can fully understand. We usher our patients in and out of waltzes with death every day. We literally take them as close to death as they'll ever be, until they die. And we almost always bring them back effortlessly. But when we don't we are dealt a blow. A blow of grief, embarassment, self-doubt and fear. We experience nausea, insomnia, saddness. It is not easy to feel somehow responsible for the death of someone who trusted you with their life. Whose parents and children and husband trusted you, too. And for your partner to help you avoid that gut-wrenching blow instills in you tremendous gratitute. But you only say, "Thank you."
Unfortunately, this patient suffered a spinal cord injury during the procedure. Her disease-ravished crumbling vertebrae could not withstand the surgical manipulation, and she woke up a permanent, ventilator-dependent quadriplegic. A risk she understood and accepted prior to surgery. In keeping with her wishes, the family gathered in the ICU three days after her surgery. Everyone said their goodbyes. She wanted no end-of-life sedation. No morphine or valium to ease the pain and anxiety of suffocation. She wanted to be fully present in her death. Her breathing tube was removed and she died within five minutes, with her husband holding her hand.
Another day at the office.
