Dr. Andrews had come in behind Dr. Mason, holding his hands up toward the ceiling in front of his chest as surgeons do after scrubbing. He waved to the group. He was a tall, slender man in his late twenties with a face as tan as Ava’s. In just about every respect except height he was the antithesis of Dr. Mason, who was stocky and broad-necked, with heavy forearms and particularly large hands and thick fingers, appearing more like a construction worker than a renowned surgeon. He was also more than twice Andrew’s age and sported a moderately protuberant belly.
“Sid is an Aussie,” Dr. Mason continued as he allowed Betsy to help him on with his gloves. He glanced over to Ava. “Have you ever been Down Under, honey?”
“I have,” Ava said. She bristled at being called “honey,” as well as the possible double entendre. “Listen! The patient’s spinal has been in for over an hour.” She was hardly in the mood for off-color repartee, if that was what Mason was intending, or travel chitchat, if he wasn’t.
“Ah, always business first,” Dr. Mason said in a mildly mocking tone. “Sid, I want you to meet one of our best anesthesiologists here at the BMH and certainly the sexiest, even in her baggy scrubs.” He laughed again while he intertwined his fingers to seat them fully into the gloves.
“Nice to meet you,” Dr. Andrews said to Ava as Betsy helped him don his gloves.
“Can we get this case going?” Ava questioned.
“She’s a pistol, Sid,” Dr. Mason said, as if Ava couldn’t hear. He stepped up to the right side of the operating table and watched while Bruce’s inguinal area was prepped. Sid went to the left side of the table. A few minutes later, amid banter about the glories of the Great Barrier Reef, the two surgeons draped the patient. Ava took the edge of the drapes facing her and secured it over the anesthesia screen with hemostats, all the while ignoring Mason’s repeated attempts to get her to join the conversation.
Once the case began with the skin incision, Ava recovered her composure enough to breathe a sigh of relief. She settled onto her anesthesia stool and checked the time. The spinal had been in place for an hour and twelve minutes. She was pleased the patient had not responded to the cutting, meaning the spinal was still totally adequate. She hoped the case would go quickly and without complication. Unfortunately, that was not to be.
The first hint of trouble was a sudden burst from Dr. Mason thirty minutes later. “Shit, shit, shit,” he blurted in obvious exasperation. “I can’t believe this.” Although the two surgeons hadn’t spoken about any technical problems, it was obvious they were struggling with something.
Ava stood up and looked down the length of the operating table. She couldn’t see into the operating field from her vantage point but could appreciate that Dr. Mason was not happy about something.
“Try to free the damn bowel from your side,” Dr. Mason said to Sid.
Ava watched as Sid leaned forward and put an index finger into the incision site. It was apparent he was working by feel.
“Is there a problem?” Ava asked.
“Obviously, there is a problem,” Dr. Mason snapped, as if it were an inane question.
“I can’t do it,” Sid admitted, pulling his hand back.
“Okay, that’s it,” Dr. Mason said, throwing up his hands in disgust. “You try to do a favor for someone and they punch you in the gut.”
Ava exchanged an eye roll with Betsy, as both knew what Mason was implying: Whatever problem had emerged, it was clearly the patient’s fault.
“We’re going to have to go into the abdomen,” Mason said irritably to Ava. “So we are going to need some decent relaxation.”
Suddenly the PA system came to life. “Dr. Mason, sorry to interrupt. This is Janet out at the main desk. Both chief surgical residents are requesting your presence in their respective rooms on your two pancreatic cases. What would you like me to tell them?”
“Jesus H. Christ!” Mason fumed to no one in particular. Then, glancing up at the speaker mounted high on the wall, he added; “Tell them to keep their damn fingers in the dike and I’ll be in as soon as I can.”
“Roger that,” Janet Spaulding said.
“If you must go into the abdomen, we have to switch to general anesthesia,” Ava said. In a way, she was relieved to switch, as she was becoming progressively worried the spinal might be wearing off. The patient was showing very slight signs that his anesthesia was getting light, with mild changes in his respiration. She gave Bruce another bolus of propofol and then carefully monitored his breathing rate and depth.
“Whatever,” Mason said. “That’s your problem. You’re the anesthetist.”
“Anesthesiologist,” Ava corrected. In her value system, being called an anesthetist was as bad as being referred to as “honey.” Anesthetists were nurses, and anesthesiologists were doctors, with a significant difference in training requirements. “What is the problem? Can you tell me?”
“The problem is we can’t reduce this little pesky knuckle of bowel caught up in the hernia,” Dr. Mason explained irritably. “So we have to go inside the abdomen. It must be freed up, and that’s the only way to do it. Anyway, you probably should have used general anesthesia from the beginning, with the GI symptoms the patient has had.”
“Your office specifically asked for spinal,” Ava said to set the record straight as she began to get out everything she would need to switch to general inhalation anesthesia. Then, to start the process, she grabbed the black breathing mask that was always within reach and turned on the oxygen supply. Deftly she put the mask on Bruce’s face. She wanted to hyperoxygenate the patient for at least five minutes before giving a muscle relaxant. She thought she would use succinylcholine as the paralyzing agent because of its rapid onset and reversal. Then, after the muscle relaxant had been given, she planned on using either an LMA, a laryngeal mask airway, or an endotracheal tube. As she was debating the pluses and minuses of these two methods of managing the patient’s airway, her mind registered the last part of Mason’s comment: the part about the patient’s GI symptoms. She didn’t remember any gastrointestinal symptoms in the chart, nor had the patient mentioned any. To be sure, she held the breathing mask with one hand and with the other opened the patient’s chart to the history and physical. A quick glance confirmed her suspicions. She had remembered correctly. There was nothing about any gastrointestinal symptoms. Had there been, she might have felt general anesthesia would have been a better choice.
“There was no mention of any GI symptoms in the history and physical,” Ava said, interrupting the surgeons’ banter, which had now turned to the Australian Outback.
“There had to have been,” Mason snapped. “It was the reason the surgery was recommended by the man’s GP.”
“I just checked the chart again,” Ava said. “There is no mention of it in the H-and-P that came over from your office.”
“What about the junior resident’s note?” Mason asked. “Did you look at that, for chrissake?”
“There is no junior resident note,” Ava said.
“Why the hell not?” Mason demanded. “There is always a junior resident’s note.”
“Not this time,” Ava said. “The patient was late to Admitting. Your fellow had done the history and physical just a few days ago. I suppose they thought that was adequate in Admitting. Maybe Admitting was backed up. I don’t know all the details except what the patient said. Your fellow also specifically told the patient he was going to get a spinal.”
“Whatever,” Mason said with a wave of his hand. “Let’s not make this anesthesia transition your life’s work, would you please! Do the switch so we can get this show on the road! As you heard from Ms. Spaulding, I’m needed elsewhere for a couple of real cases.”
“Had you been part of the pre-op huddle, this could have been avoided,” Ava said under her breath.
“Excuse me!” Mason thundered. “Are you lecturing me? Do you forget who I
am?”
“I’m just making a comment,” Ava said, trying to back off. “The purpose of the pre-op huddle is precisely to avoid situations like this.”
“Really, now?” Mason questioned mockingly. “Thank you for telling me. I’ve always wondered what the reason was for those little gatherings, even though I was one of the originators of the idea way back when. But tell me! How long do we have to wait before we can get back to work here?”
“Another minute with the one hundred percent oxygen,” Ava said, glad to change the subject. She was already deriding herself for provoking Mason. She wondered what she was thinking. She took a deep breath to clear her mind and switch her total attention to the problem at hand, particularly regarding the airway. With general anesthesia, the airway was the critical component. The laryngeal mask airway was easier and quicker but not as secure or safe. Responding to more of a gut feeling than anything else, she elected to go for the endotracheal tube with its added safety. Later, she would have reason to question why she came to this decision.
Still holding the face mask with one hand, Ava got out the appropriate-sized endotracheal tube, along with the laryngoscope she would use to place it. She tested the suction unit to be sure it was functioning in case it was needed. In the background the low-volume but ultra-high pitch of the oxygen oximeter alarm reassured her that the patient was fully oxygenated. She checked the time. Five minutes had passed. Luckily, Mason had already forgotten the little squabble about the pre-op huddle. He and his assistant were back to talking about scuba diving.
Quickly putting the breathing mask to the side, Ava gave a one-hundred-milligram bolus of succinylcholine intravenously. There was some minor fasciculation of Bruce’s facial muscles, but nothing abnormal. Most important, the pulse and blood pressure stayed the same. After tilting the patient’s head back, Ava inserted her right thumb into Bruce’s mouth to lift his lower jaw as she slid the blade of the laryngoscope held in her left hand under and behind his tongue. Letting go with her right hand, she reached for the endotracheal tube.
Although Ava had used a laryngoscope and placed endotracheal tubes thousands of times, the process always put her on edge, giving her a rush and reminding her why she loved the process of anesthesia even though the vast majority of the time it was routine. The feeling reminded her of the one time she had been talked into skydiving. Her mind was sharp, her senses honed to a razor’s edge, and she could feel her own elevated pulse in her temples. Although the patient was more than adequately oxygenated after the 100 percent oxygen, he was now not able to breathe due to his paralysis from the muscle relaxant, so time was of the essence. She had about six to eight minutes to commence breathing for him before the extra oxygen would be used up and he would begin to asphyxiate.
Deftly, Ava advanced the laryngoscope blade into the depression above Bruce’s epiglottis and gently but firmly lifted the laryngoscope up toward the ceiling to pull his mandible and tongue forward. A moment later she was rewarded with a clear view of the man’s vocal cords and the opening of his trachea. Without taking her eyes off the target, she had brought the endotracheal tube into view with her right hand with the intention of inserting its tip into the trachea when the view disappeared. To Ava’s horror, the man’s mouth had suddenly filled with fluid and a mixture of undigested food.
“My God!” Ava blurted as her heart leaped in her chest. The man had regurgitated an apparently full stomach, which wasn’t supposed to happen, since he had been told not to eat or drink anything after midnight except possibly a bit of water. Obviously, he had ignored the warning and had consequently created an anesthetic emergency of the highest order. Although Ava had never experienced this complication of such a large amount of vomitus with a live patient, she had practiced innumerable times handling such a situation with a simulator and knew exactly what to do. First, she turned the man’s face to the side to allow all that could to run out of his mouth while at the same time tilting the whole table to get his head lower than the rest of his body. Then she grabbed the suction device and rapidly sucked out the remainder of the vomitus from Bruce’s pharynx. What worried her the most was how much had gone down the man’s trachea.
“What the hell?” Mason questioned with alarm when the table unexpectedly tilted. He stepped around the ether screen, glaring at Ava. Dawn, the circulating nurse, leaped off her stool in the corner and came around to the other side.
Ava ignored both. She was too busy. Retrieving the laryngoscope and the endotracheal tube, she repeated the process she had done earlier and this time inserted the endotracheal tube. Once it was in and sealed, she used a narrow, flexible tip on the suction device and threaded it down the endotracheal tube and sucked out as much vomitus as possible, progressively advancing the suction tip deeper into the man’s chest. It was at that point that the cardiac alarm went off. A glance at the ECG showed the heart had gone into fibrillation, meaning the heart was no longer pumping. An instant later the blood-pressure alarm went off, meaning the blood pressure was falling to zero. Then the pitch of the oximeter alarm began to decrease as the oxygen saturation fell.
“Call a code,” Ava shouted to Dawn.
Betsy immediately spread a sterile towel over the open incision while Mason and Andrews yanked the drapes off the anesthesia screen and folded them down, exposing the man’s thorax. While Andrew pushed Bruce’s gown up around his neck, exposing his chest down to his belly button, Mason slapped him on the sternum with an open palm hard enough to jar the man’s body. Everyone watched the ECG, hoping to see a normal rhythm, but there was no change. Ava continued to suck out vomitus from the man’s trachea as far down as his bronchi. Mason hit Bruce’s chest again, this time using the side of a closed fist. Still no change. Andrews leaned over the patient and began closed-chest cardiac massage.
The OR door burst open and in rushed several senior anesthesiology residents with a defibrillation machine. Ava yelled that the patient was in fibrillation. Dr. Mason and Dr. Andrews stepped away from the table as the two new arrivals went ahead and immediately shocked the patient. To everyone’s relief, a normal sinus rhythm reinstituted itself immediately. The pitch of the oxygenation alarm began to rise, indicating an increase in blood oxygen. At the same time the blood-pressure alarm went silent, although the blood pressure rose to only 90 over 50.
Pleased at their success, Dr. David Wiley and Dr. Harry Chung pushed the defibrillator out of the way and joined Ava at the head of the table. As they watched the ECG to make sure the rhythm was stable, she told them what had happened: “Massive regurgitation and aspiration when I tried to intubate. Obviously, the patient had a full meal this morning despite denying having had anything by mouth. He flat out lied to me and the admitting nurse. As you can see in the suction bottle, I’ve sucked out over three hundred cc’s of fluid and undigested food, including bits of bacon and other poorly chewed material.” She pulled out the suction catheter and connected an ambu bag to the endotracheal tube. The ambu was attached to 100 percent oxygen. Immediately she began attempting to respire the patient by compressing and releasing the bag.
“Jesus,” Dr. Mason complained. “This was supposed to be a simple hernia.”
“Has it been about eight minutes since you gave the muscle relaxant?” Harry asked, looking at the anesthesia record and ignoring Dr. Mason.
“About that,” Ava said. “I’m hoping we’ll be okay in that regard. I gave him a full five minutes with pure O2 before the succinylcholine.”
“How does the resistance feel when you breath him?” David asked.
“Not good,” Ava admitted. She was thinking about the raised resistance the moment David brought it up. It was subtle but definite. It was a sensitivity born of experience of breathing for thousands of patients under all sorts of circumstances. With the succinylcholine on board, there should have been very little resistance to expanding the lungs. “To be sure, you try, while I listen to his chest.”
David took over the ambu bag while Ava used the stethoscope.
“Breath sounds are terrible bilaterally,” Ava said.
“I agree there is too much resistance,” David said. “The bronchi must be full of vomitus and seriously occluded. I don’t think we have much choice. We are going to have to bronch him.”
Suddenly the pitch of the oximeter alarm began to fall again, indicating that too little oxygen was getting into the blood with the bronchial blockage, despite David’s efforts.
The door to the OR opened and in rushed Dr. Noah Rothauser, a senior surgical resident who was scheduled to be the super chief surgical resident come the first of July, less than a week away. He was tying a face mask over the top of his head. Practically everyone knew Noah. It was generally felt that he was the best surgical resident the BMH had ever produced. A few jealous colleagues wondered if he was too good, as he had consistently gotten the highest grades recorded on the biannual American Board of Surgery In-Service Exams. He was known to be a tireless worker, extraordinarily knowledgeable for a resident, decisive, and remarkably congenial for a surgeon. As was typical of his commitment, the moment he’d heard about the code while he was in the surgical lounge, he came running to see if he could lend a hand.
The scene that confronted Noah wasn’t auspicious. The two surgeons were standing immobilized a step back from the table that was tilted in a head-down position. Their hands were clasped in front of their chests. The patient was supine, naked from his head to his umbilicus, with his hospital gown bunched up under his chin. His color was a disturbing shade of slate blue, and his chest didn’t seem to be moving. Three anesthesiologists were grouped around the patient’s head, and one of them was yelling for the circulating nurse to get a bronchoscope stat while trying to use an ambu bag.
“What’s going on?” Noah asked urgently as Dawn rushed out the door for the bronchoscopy setup. Noah heard the pitch of the oximeter alarm falling, and then at that very moment he heard the blood-pressure alarm go off. By instinct honed from experience he knew that the situation was critical and the patient’s life was hanging in the balance.