“You’re late,” the woman said with a mildly accusatory tone of voice. She had an uncanny visual resemblance to Carl’s sixth-grade teacher, Miss Gillespie. The association made him feel as if he were going back to an earlier stage in his life when he truly wasn’t in control of his fate. Carl had been an irrepressible twelve-year-old and had clashed with Miss Gillespie. The clerk picked up a packet of paperwork that was on the desk in front of her and handed it to Carl. “Take a seat! A nurse will be with you shortly.”
Although similarly as bossy as the clerk, the nurse was significantly more congenial. She smiled when she asked Carl to follow her back to a curtained-off area where there was a gurney made up with fresh sheets and a pillow. Draped across it was the infamous hospital johnny. After checking his picture ID and asking his name and birth date, she put a name tag on his wrist. Once that was done, she told him to put his valuables in a zippered canvas bag that was also on the gurney, take off his clothes, put on the johnny, and lie down. From the inside, she pulled the curtain around to allow privacy. She watched as Carl picked up the johnny and tried to figure out how it was supposed to be worn.
“The opening should be in the back,” the nurse said, as if that were going to solve Carl’s confusion. “I’ll be back shortly when you are done.” She then disappeared through the curtain. It was apparent she was in a hurry.
Carl did as he was told but had trouble with the johnny, particularly in terms of figuring out how to secure it. One tie was at the neck, the other at the waist, which made no sense. He did the best he could. No sooner had he gotten onto the gurney and pulled the sheet up around his torso than the nurse was outside the curtain, calling to ask if he was finished.
Back inside the curtain, the nurse then went through a litany of questions: Did you eat anything this morning? Do you have any allergies? Do you have any drug intolerance? Do you have any removable dentures? Do you smoke? Have you ever had anesthesia? Have you had any aspirin in the last twenty-four hours? It went on and and on, with Carl dutifully answering no over and over until she queried how he felt.
“What do you mean?” Carl asked. He was taken aback. It was an unexpected question. “I feel nervous. Is that what you are asking?”
The nurse laughed. “No, no, no! I mean do you feel well right now and did you feel normal during the night. What I’m trying to ask is whether or not you feel like you might be coming down with something. Have you had any chills? Do you feel like you have a fever? Anything like that?”
“I get it,” Carl said, feeling embarrassingly naive. “Unfortunately I feel fine health-wise, so there’s no excuse not to go forward with all this. To be honest I’m just anxious.”
The nurse looked up from her tablet, where she had been recording all of Carl’s responses. “How anxious do you feel?”
“How anxious should I feel?”
“Some people find the hospital stressful. We who work here don’t because being here is an everyday event. You tell me, say on a scale of one to ten.”
“Maybe eight! To be honest, I’m really nervous. I don’t like needles or any other medical paraphernalia.”
“Have you ever had a hypotensive episode in a medical setting?”
“You’ll have to translate that into English.”
“Like fainting?”
“I’m afraid so. Twice. Once having my blood drawn for some tests in the college infirmary, and once trying to give blood in college.”
“I’m going to note this in your record. If you’d like, I’m sure they will give you something to calm you down.”
“That would be nice,” Carl said, and he meant it.
The nurse took Carl’s blood pressure and pulse, which she remarked were normal. She then had a conversation with Carl about which knee was to be operated on, and when Carl pointed to his right knee, she made an X with a permanent marker on Carl’s thigh, four inches above his right kneecap. “We want to be sure not to operate on the wrong knee,” she said.
“Me too,” Carl responded with alarm. “Has that ever happened?”
“I’m afraid so,” the nurse said. “Not here, but it has happened.”
Holy fuck, Carl thought. Now he had something else to worry about. As nervous as he felt, he wondered if he had been wrong in discouraging Lynn from coming by to at least say hello before the procedure. Maybe he needed an ombudsman.
• • •
Dr. Wykoff, the patient is in the CSPC,” Claire said, coming back into OR 12, referring to the center for surgical patient care, an extra-long name for the patient holding area.
“How about Dr. Weaver?” Sandra responded.
“He’s changing. We’re good to go.”
“Perfect,” Sandra said. She stood and picked up her computer tablet. “How are you doing, Jennifer?” Jennifer Donovan was the scrub nurse, who was already gowned, gloved, and setting out the sterilized instruments. It was 7:21 A.M.
“I’ll be ready,” Jennifer said.
As Sandra walked back down the central corridor, she checked Carl’s EMR and noticed the admitting nurse’s entries. There were no red flags for trouble. The only thing she picked up on was that the patient was unusually anxious and had a history of several hypotensive episodes in the past associated with drawing blood. In Sandra’s experience she’d come across a number of men with such a phobia, but it had never been a problem. People rarely fainted when lying down. As far as she was concerned, anxiety was par for the course. That’s why she liked midazolam, or Versed, so much. It worked like a charm, relaxing even the most skittish patients. In the pocket of her scrubs she had a syringe with the proper dose, according to Carl’s weight.
She found Carl Vandermeer in one of the pre-op bays of the CSPC. She couldn’t help but notice that he was a handsome man with dark, thick hair and startlingly wide-open blue eyes. Except for his apparent anxiety, he was the picture of health. The thought went through her mind that working with him was going to be a pleasure.
“Good morning, Mr. Vandermeer,” Sandra said. “I’m Dr. Wykoff, I will be your anesthesiologist.”
“I want to be asleep!” Carl stated with as much authority as he could muster under the circumstances. “I went over this with Dr. Weaver, and he promised me that I would be asleep. I don’t want an epidural.”
“No problem,” Sandra said. “We’re all prepared. I understand you are a little anxious.”
Carl gave a short, mirthless laugh. “I think that is an understatement.”
“We can help you, but it does require me to give you an injection. I know you don’t like needles, but are you okay with getting one? It will help, I guarantee.”
“To be truthful, I’m not excited about it. Where will you give it?”
“Your arm will be fine.”
Steeling himself, Carl dutifully exposed his left arm and looked away to avoid seeing the syringe. After a quick swipe with an antiseptic wipe, Sandra gave the injection.
Carl turned back. “That was easy. Are you finished already?”
“All done! Now I want to go over with you the material the admitting nurse recorded.”
Rapidly Sandra asked the same questions about Carl not having had anything to eat since midnight, about allergies, about drug intolerance, about medical problems, about previous anesthesia, about removable dentures, on and on. By the time Sandra got to the end, Carl’s attitude had completely changed, thanks to the midazolam. Not only was he no longer anxious, he was now finding the whole situation entertaining.
At that point, Sandra started her IV. Carl couldn’t have cared less and watched her preparations with a sense of detachment. It helped that she was extremely confident and competent with the procedure. She always made a point to start her own so she could trust it. She used an indwelling catheter rather than a simple IV. Carl never stopped talking through the process, particularly about his girlfriend, Lynn Peirce, who he s
aid was a fourth-year medical student and the best-looking woman in her class. Sandra diplomatically let the issue drop.
A few minutes later Dr. Gordon Weaver appeared to have a few words with Carl, including which knee they were going to work on. He checked that the X that the admitting nurse had made with the permanent marker was on the proper thigh.
“You people are really hung up on which knee,” Carl joked.
“You better believe it, my friend,” Dr. Weaver said.
With Sandra guiding in the front and Dr. Weaver pushing from the back, they wheeled Carl down and into OR 12, stopping alongside the operating table directly under the operating room light. Somewhere en route Carl had drifted off into light sleep in midsentence, again reminding Sandra why she was so fond of the midazolam. Only much later would Sandra question the dose she had given in the process of reviewing everything she had done. Sandra, Dr. Weaver, and Claire Beauregard moved Carl over onto the operating table with practiced efficiency.
When Dr. Weaver went out to scrub, Sandra pulled the anesthesia machine close to Carl’s head. This was the part of the case that she liked the best. She was center stage and about to prove once again the validity of the science of pharmacology. Anesthesia was a specialty marked by extreme attention to detail; periods of intensive activity, like what she was now beginning; and then long segments of relative boredom, which required dedicated effort to stay focused. Whenever she thought about it, the analogy of being a pilot came to mind. At the moment she was about to take off. After that had been accomplished she would be in the equivalent of midflight autopilot and have little to do besides scanning the monitor and the gauges. It wouldn’t be until the landing that she’d again be called upon for intense activity and attention to detail.
Since there were no specific contraindications to any of the current anesthetic agents, she planned on using isoflurane, supplemented with nitrous oxide and oxygen. She had used the combination in thousands of cases and felt comfortable with it. There was no need for any paralyzing drugs because a knee operation didn’t require any muscular relaxation like with an abdominal operation, and she wasn’t going to use an endotracheal tube. Instead she would use what was known as a laryngeal mask airway, or LMA. Sandra was a stickler for detail in all aspects of her life but most specifically for anesthesia, and had never had a major complication.
Like all anesthetists who are specially trained nurses and anesthesiologists who are specially trained doctors, Sandra knew that the ideal anesthetic gas should be nonflammable, should be soluble in fat to facilitate going into the brain, but not too soluble in blood so that it could be reversed quickly, should have as little as possible toxicity to various organs, and should not be an irritant to breathing passageways. She also knew that no current anesthetic agent perfectly fulfilled all these criteria. Yet the combination she intended to use with Carl came close.
The first thing that Sandra did was to set up all the patient monitoring so that she would have a constant readout of Carl’s pulse, ECG, blood oxygen saturation, body temperature, and blood pressure, both systolic and diastolic. The anesthesia machine would monitor the rest of the levels that needed to be watched, such as oxygen and carbon dioxide levels in inspired and expired gases and ventilation supply variables.
As Sandra positioned the monitors, particularly the ECG leads and the blood pressure cuff, Carl became conscious. There was no anxiety on his part. He even joked that with everyone wearing masks it was like being at a Halloween party.
“I’m going to give you some oxygen,” Sandra said as she gently placed the black breathing mask over Carl’s nose and mouth. “Then I will be putting you asleep.” Patients liked that comfortable metaphor rather than what Sandra knew anesthesia really to be: essentially being poisoned under controlled and reversible circumstances.
Carl didn’t complain and closed his eyes.
At that point Sandra injected the propofol, a fabulous drug in her estimation that was unfortunately made infamous by the Michael Jackson tragedy. Knowing what propofol did to arterial blood pressure, ventilation drive, and cerebral hemodynamics, Sandra would never give the drug to someone without appropriate physiologic monitors and a primed and ready anesthesia machine.
In the induction phase, Sandra was now in her most attentive mode. With an eagle eye on all the monitors she continued to use the black breathing mask to allow Carl to breathe pure oxygen. In the background she was vaguely aware of Dr. Weaver coming into the room and putting on his sterile gown and gloves. After approximately five minutes, Sandra put the breathing mask aside and picked up the appropriately sized LMA. In a practiced fashion she inserted the triangular, inflatable tip into Carl’s mouth and pushed it into place with her middle finger. Quickly she inflated the tube’s cuff and attached the tube from the anesthesia machine. The immediate detection of carbon dioxide by the anesthesia machine in the exhaled gas suggested the LMA was properly seated. But to be sure, Sandra listened to breath sounds with her stethoscope. Satisfied, she taped the LMA tube to Carl’s cheek so that it could not be moved. She then dialed in the proper levels of isoflurane, nitrous oxide, and oxygen. The nitrous oxide had some anesthetic properties but not enough to be used on its own. What it did do was lessen the amount of isoflurane needed, which was helpful, because the isoflurane did have some mild irritant effects on breathing passageways. She then taped Carl’s eyes shut after putting in a bit of antibiotic ointment to protect his corneas from drying.
Sandra watched the anesthesia machine with its readout of all the vital signs. Everything was in order. The takeoff had been smooth. Metaphorically they were nearing cruising altitude and soon the seat belt sign could go off. Sandra’s pulse, which had jumped considerably during the induction of anesthesia, dropped back to normal. It had been a tense few minutes, as it always was, yet it provided her a shot of euphoria of a job well done and a patient well served.
“Everything okay?” Dr. Weaver questioned. He was eager to begin.
Sandra gave a thumbs-up as she manually checked Carl’s blood pressure yet again. She then helped Claire put up the anesthesia screen, which would be covered with sterile drapes to isolate the patient’s head from the sterile operative field. After the screen was in place she sat back down. She was now in midflight.
As he worked during the course of the operation, Dr. Weaver kept up a mostly one-sided conversation with everyone in the room. He talked about what he was doing technically as he fashioned the patellar graft, he talked about his kids, and he talked about his weekend house on Folly Island.
Sandra listened with half an ear, as she imagined the scrub nurse and circulating nurse did as well. Sandra spoke up only once when there was a break in Dr. Weaver’s monologue. She took the opportunity to ask how long he thought he’d be.
The surgeon straightened up, paused briefly, and assessed his progress. “I’d guess another forty minutes or so. It’s all going smoothly. Everything okay up there with you?”
“Everything is fine,” Sandra said. She glanced down at her notes. The machine did the anesthesia report in contrast to the old days, but she kept her own record for her own use and to remain focused. Another forty minutes would put the total time for the procedure at just a little more than an hour and a half, meaning Dr. Weaver was acting true to form. There were other orthopedic guys who would take nearly double his time.
Sandra moved a bit to keep her circulation going and stretched out her legs. She had the option of having someone come and relieve her for a few minutes if she so desired, but she rarely took advantage of the opportunity and wouldn’t now, even though everything was going perfectly smoothly.
Sandra heard the sound of the drill start, meaning Dr. Weaver was creating a pathway through bone into which he would thread the patellar allograph. Knowing that the periosteum was richly enervated with pain fibers, Sandra looked up at the integrated patient monitor screen to see if there were any observable changes to sugge
st Carl’s level of anesthesia wasn’t what it should be. All the tracings were exactly as they had been throughout the case. She homed in on the heart rate. It was at seventy-two, without the slightest change. But as she was watching, the screen did something she had never seen it do before. It seemed to blink, as if for a split second it had lost its feed.
A bit concerned about this blip, Sandra leaned closer to get a better look as her own pulse ratcheted upward. The idea of losing all the monitors in the middle of the case was not a happy thought. Holding her breath, she watched to see if there was another episode. A few seconds went by and then a few minutes. There wasn’t another blink.
After five minutes she began to relax, especially since the tracings on the monitor all stayed completely normal, including the ECG. Whatever it had been clearly hadn’t happened again. The only change, and she wasn’t even sure there had been a change, was that all the tracings appeared very slightly higher on the screen than they had been, as if there had been a slight baseline or calibration change. But that couldn’t have happened, because she hadn’t changed anything.
Sandra shook her head as if to loosen imagined cobwebs. Maybe she did need a break. Yet her fear that the possible artifact had been real kept her glued to her seat and watching the patient monitor closely. It was mesmerizing as the tracings raced across the screen, particularly the ECG, with its rapid, repetitive, staccato up-and-down movements.
After about ten minutes Dr. Weaver got Sandra’s attention by telling her that he was within twenty minutes from closing the skin. That meant that her second most busy time had arrived. She shut off the isoflurane but maintained the nitrous oxide and oxygen. The second she did so, disaster struck! The blood oxygen alarm went off, making Sandra jump.
Sandra’s eyes shot to the monitor. The oxygen had suddenly gone from nearly 100 percent down to 92 percent. That wasn’t terrible, but it was a change, as it had been pegged at maximum during the whole case. It was also encouraging that it was now at 93 percent and already heading upward. But why did it drop? Sandra didn’t have the foggiest notion. That was when she noticed the ECG had changed, too. At the same moment the oxygen level had fallen, there was sudden tenting of the T wave, suggesting endocardial ischemia, meaning lack of adequate oxygen to the heart. That was not good. But how could it be? How the hell could the heart be lacking oxygen when the blood level hadn’t changed but an instant earlier and not by much? This was nuts!