ADRENALINE: New 2013 edition (19 page)

Halfway through her suture count, she noticed she was missing some 3-0 Vicryl on a P-3 cutting needle. She knew Dr. Alfonse was a stickler about these things and would whine unmercifully if she didn’t have it. She started across the hall toward OR#1 where a large supply cabinet of suture material was located. Halfway across the hall, she noticed that the lights were out in OR#1. She didn’t give it much thought, as it wasn’t that unusual. She simply assumed they must’ve broken for lunch and turned the lights off when they left.

As she approached the door, she stopped and hesitated a moment. Through the small window in the heavy wooden door, some motion caught her eye. She thought she could make out a shadowy figure at the opposite end of the room where the anesthesia equipment was. The shape seemed to be moving quickly towards the other door at the far end of the room. Strange, she thought, that someone would be in there working in the dark.

She shook her head briefly to dispel the growing fear, pushed the door open, and entered the room. As she turned and groped for the light switch, she distinctly heard the creaking of the far door as it closed. The lights blazed on and bathed the room in bright white, hospital-approved light. The room was empty.

Melissa walked over to the suture cabinet, opened the doors and retrieved her missing suture. She had the unmistakable sensation that someone was watching her through the window in the far door. The window shade was pulled down, so she couldn’t see, but she was convinced someone was on the other side. It gave her
an acute condition of “cutis anserina” or goose bumps. She considered for a moment walking over and opening the door, but she couldn’t summon the proper courage. All she could manage was a long stare. Soon she turned around and rapidly exited the room with her precious suture in hand.

CHAPTER FIFTEEN

Doug hated Mondays, especially those following a call weekend. Only halfway through the day and he already felt bushed. He summoned some additional energy and went to meet his noontime patient. There were seven patients awaiting surgery crammed into the small holding area. The scene frequently reminded Doug of a busy stockyard where the patients were the cattle. He squeezed in between two of the litters to get to his patient. Doug extended his hand to the big man lying on the litter in front of him.

“Mr. Lehman, Hi I’m Doctor Landry. I’ll be helping you go off to sleep today, so we can fix your hernia.”

“Hello, Doctor Landry. Nice to meet you.” Bob Lehman grasped Doug’s hand and pumped his arm hard with a grip somewhere between firm and crushing.

“How are you doing today?” Doug asked, extricating his hand quickly to avoid injury.

“Just fine,” Mr. Lehman replied. “That shot really helped me relax. I’m kinda hungry, though.”

Doug glanced at his watch—12:05 p.m. “Yeah, I agree—that’s the worst part. So, nothing to eat or drink after midnight, right?”

“Not a thing. And let me tell you, just between you and me.” Mr. Lehman lowered his voice conspiratorially and Doug leaned closer. “I don’t miss many meals.” Mr. Lehman patted his ample midsection and grinned. “I’d settle for a cup of coffee right now. It doesn’t help when they wheel you right past that coffee machine over there.” He pointed across the hallway to the surgeon’s lounge. “Smells great.”

“Yeah, pretty cruel, I know. But you want your surgeon to be awake, right?” Doug paused and glanced at Mr. Lehman’s chart. The only thing that really stood out in his history was his recent bypass procedure. Doug hoped Mr. Lehman’s heart was in as good shape as the rest of him seemed to be. “I’ve read through your chart and everything seems to be in order. Any questions for me?”

“No, let’s get it over with.”

“Left-sided hernia, correct?” Doug asked.

“Right—I mean yes, left.”

Both men chuckled, and Doug wheeled the litter down the hall toward OR#1. Doug instinctively liked the big man although he knew it was a mistake to become too chummy. Always better to keep the relationship professional.

Once inside the room, Mr. Lehman transferred himself from the litter to the OR table with help from the circulating nurse, Sue Hoffman. Doug was impressed that he moved so adroitly for such a big man.

“Just when I got that one warmed up you make me move to this cold bed,” Mr. Lehman complained, although he had a smile on his face. “Not very comfortable either.”

“I’ll get you a warm blanket in a minute,” said Sue Hoffman. “First, we must put this strap on so you don’t fall off this narrow table.” She snugged a six-inch-wide leather strap that meant business around Mr. Lehman’s upper thighs, effectively fixing him to the table. Doug often wondered what patients must think of this
strap; it seemed to be a direct descendant from the days of the Inquisition.

“Bed’s kinda small,” Bob Lehman commented as he looked around the room.

“Yep,” Sue said, placing the blanket over him. “Not designed for comfort, are they?”

“I’m gonna be hooking you up to some monitors here, Mr. Lehman,” murmured Doug as he fell into his pre-induction monologue. “Just routine.” He had long ago hit upon what he considered the best combination of phrases to help inform and relax the patient. He knew very well that this was a particularly stressful time for most patients, pre-op medication notwithstanding. He remembered being in this position himself several years ago and literally shaking as he climbed onto the OR table. He also knew his monologue helped to relax himself as well and couldn’t help but notice that he felt strangely on edge.

“I need your right arm out here.” He ripped Velcro and wrapped a blood pressure cuff around Mr. Lehman’s arm, hoping it would fit. “This is a blood pressure cuff. It’s going to pump up and squeeze your arm. It’ll let go in a minute.” He activated the automatic blood pressure machine. “These are sticky EKG patches, so we can monitor your heart.” He placed the first two. “And this last patch goes on your left side, and it’s the coldest of all.”

“Yikes,” said Mr. Lehman. “First you warm me with the blanket, and then you freeze me.”

“Now put your left arm out to this side. I have a little clip that goes on your finger and tells me how well you’re breathing.” Doug placed the pulse oximeter finger sensor.

“It feels like I’m being crucified,” Mr. Lehman remarked, wiggling his outstretched arms.

“Well, it
is
a Catholic hospital, Bob,” Doug said with mock seriousness, then added quickly, “Just kidding.”

“Thank God it’s not Good Friday,” Mr. Lehman said and laughed.

“Yeah, right,” Doug said as he quickly glanced at the monitors to get some baseline numbers. BP was 145/90, pulse was 78, and O2 sat was 96% on room air. The EKG trace showed normal sinus rhythm. Everything looked good.

“I’m going to give you some medicine to help you relax while we get you set up here.” Doug administered two cc’s of Fentanyl, a potent narcotic used to blunt the patient’s response to pain. He couldn’t help but think of Mike; Fentanyl was the same drug Mike was abusing. He had a vision of Mike sitting in a bathroom stall injecting himself. He forced himself back to Mr. Lehman. “Here’s some oxygen I want you to breathe.” He placed the mask, which was hooked up by plastic hoses to his anesthesia machine, on Mr. Lehman’s face. Doug dialed the oxygen flowmeter to five liters-per-minute. Doug watched the pulse oximeter reading rise from 96% to 100% as Mr. Lehman’s lungs filled with 100% oxygen. “Are you feeling any of that medicine yet?” Doug asked.

“Yes, I believe I am,” came Mr. Lehman’s muffled response from under the mask.

“OK, now it’s time to pick out a pleasant dream. You’ll be going off to sleep in about a minute.”

“OK, Doc. I’m on the beach in Bermuda,” Mr. Lehman said smiling. “On my honeymoon.”

Doug thought of Aruba and his own honeymoon. He and Laura had been so happy. Where in God’s name had they gone wrong? Just yesterday, Laura had tried to make up to him. He hadn’t realized it at the time; he had been too busy projecting coldness. By the time he figured it out, the fragile moment had passed. Perhaps his encounter with Jenny had blinded him to Laura’s intentions?

Mr. Lehman’s voice brought him back to the present. “I’m in your hands, Doc.”

Doug hated it when they reminded him of that. He turned around to get the necessary induction drugs. About twelve syringes filled with the basic anesthetic meds of his trade lay at the ready
on top of his anesthesia cart. He reflected briefly on the fact that here before him was a deadly arsenal of drugs. Each syringe was potentially lethal if given in the wrong amount, wrong combination, or wrong order.

Doug shook his head to break this destructive line of thought and hooked the Diprivan syringe to the IV set and injected the entire contents. “OK. Here we go. You’re going to drift off to sleep in about thirty seconds.”

All twenty cc’s of the thick, white emulsion snaked through the IV tubing toward Mr. Lehman’s hand, where it buried itself in a vein. Doug could feel his own heartbeat quicken and his senses snap into focus as he pushed the Diprivan. Whenever he induced a patient, he was keenly aware of taking several irreversible steps—the first being the administration of the induction agent.

Very quickly Mr. Lehman’s jaw sagged, his eyes closed, and he stopped breathing. Doug checked for the absence of a lid reflex by gently touching his eyelids to assure himself that Mr. Lehman was unconscious. He then grasped the mask with his left hand, tightly applied it to Mr. Lehman’s face to effect a seal, and squeezed the breathing bag on the anesthesia machine. He gave Mr. Lehman a couple of quick breaths by forcing air into his lungs. After checking to make sure he could ventilate his patient, Doug moved on to the next irreversible step—this one bigger than the last.

He injected 160 milligrams of Succinylcholine, a muscle relaxant that temporarily produces a muscular paralysis necessary for intubation. A strange wave of muscle rippling traveled through Mr. Lehman’s body as the Succinylcholine exerted its effect and rendered his muscles completely flaccid.

Doug took his laryngoscope, a barbaric-looking metal device with a bright light on one end, in his left hand and opened Mr. Lehman’s mouth with his right. He slid the laryngoscope blade in and hunted for the glottis, which is the opening to the trachea. The laryngoscopy triggered a strong déjà vu. Doug imagined he could feel Jenny pressed up against him, and he could even smell
her perfume. He suppressed the memory angrily and glanced around to see if anyone had noticed his hesitation. Sue was busy filling out her paperwork, and the scrub nurse was counting her instruments.

He refocused on Mr. Lehman’s vocal cords, which were asleep on the job, paralyzed by the Succinylcholine. With his right hand, Doug carefully inserted the endotracheal tube through the opening between the vocal cords and pushed it several inches down into the trachea. He removed the laryngoscope blade from Mr. Lehman’s mouth, inflated the cuff at the end of the endo tube, and hooked it up to his breathing circuit. As he squeezed the bag, Doug watched Mr. Lehman’s chest rise and fall. He quickly listened to both sides of Mr. Lehman’s chest with his stethoscope to check for equal breath sounds. Hearing good sounds bilaterally, Doug flipped on the ventilator and dialed in two-percent Isoflurane gas and some nitrous oxide. This would keep Mr. Lehman asleep as the Diprivan wore off.

Doug barely had time to tape the endotracheal tube in place before all hell broke loose. Doug heard the EKG monitor alarm sing out first, and he snapped his head to look at it.

“V-tach! Shit!” he mumbled to himself. “Where the hell did that come from?” He paused for an instant and then said loudly, “Sue, get some help in here stat and bring the crash cart! Got trouble!”

Doug rarely called for help. He had confidence in his abilities to solve most problems, but he recognized true emergencies when he saw them and knew calling for help early was sometimes key; the first five minutes of a crisis were critical. The malpractice records were replete with stories of bad outcomes related to delayed diagnosis and treatment of emergency situations.

“Think, Think,” he muttered to himself. “Must’ve been playing possum.” Doug figured that Mr. Lehman may have appeared to have been adequately anesthetized just prior to intubation but actually wasn’t. He knew that intubation is a very stimulating
procedure. It can cause a grossly elevated BP and a dangerously rapid heartbeat and/or V-tach in a sick heart.

Doug didn’t wait for his BP machine to cycle. He quickly turned his anesthetic agent to the max and in rapid succession administered as much Fentanyl as he had, injected one syringe of premixed emergency Lidocaine, and gave some Labetalol. In so doing, Doug went way out on a limb. His clinical instinct told him his patient had an exaggerated sympathetic response to the intubation; an outpouring of adrenaline from his adrenal glands in a classic flight or fright response. Doug didn’t have all the facts in yet, but sometimes waiting the extra thirty seconds to be sure of the diagnosis could cost thirty seconds of treatment time and push you over the edge into irreversible damage. He had just given enough drug to dangerously lower a normal person’s BP. But, it may have been lifesaving in a hypertensive crisis.