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THE ANESTHESIA CONSULTANT

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com

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The first chapter of Doctor Vita by Rick Novak opens with a scene unlike any you’ve ever read before.

Chapter 1    THE BRICKLAYER

Alec Lucas’s first contact with FutureCare came in operating room #19 at the University of Silicon Valley Medical Center, where his patient Elizabeth Anderson blinked into the twin suns of the surgical lights hanging from the ceiling. A clear plastic oxygen mask covered Elizabeth’s nose and mouth, her cheeks were pale and tear-stained, and a strand of gray hair protruded from a blue paper bonnet. Her hand trembled as she reached up to remove the mask.

“I’m scared,” she said.

“I’m not,” said Dr. Lucas, who was her anesthesiologist. A green paper mask covered his face, but his pale blue eyes sparkled at her. He hummed to himself as he injected a dose of midazolam into Elizabeth’s IV to relax her.

“Am I crazy to go through this?” she said. “A 78-year-old lady with cancer?”

“We’re hoping your cancer can be cured with surgery,” Alec said. “Right now you’re doing great. Everything is perfect. Have a wonderful dream.” Elizabeth had cancer of the stomach, and presented today for robot-assisted laparoscopic surgery to remove half her stomach. It was a huge surgery—a risky surgery. Alec wondered why they were doing this operation on this lady. He questioned the aggressive strategy for a woman this old, but his job was to anesthetize, not to philosophize.

He’d seen presurgery anxiety like hers hundreds of times. The best way to cure her fears was to get her off to sleep. He injected doses of propofol and rocuronium into her intravenous line. The drugs flowed into Elizabeth’s arm, and within ten seconds her eyes closed. He inserted the lighted blade of a laryngoscope into her mouth, and visualized the white and shining upside-down “V” of her vocal cords, hovering in a sea of pink tissue. He slid a hollow plastic tube between the cords and into the blackness of the trachea beyond. Then he activated the ventilator, which blew a mixture of oxygen and sevoflurane through the tube into her lungs.

“I haven’t worked with you before, Dr. Lucas,” said the circulating nurse, who stood at the patient’s side. “My name is Maggie.”

“Of course you’ve never worked with me,” he said. “I told the nursing supervisor I never wanted to work with Maggie.” Then he winked at her and said, “We haven’t worked together because today is my first day on staff here. I’ve been at the University of Chicago since my first day of medical school. After fifteen years of shoveling snow, it was time to give California a try.”

Alec looked up as the surgeon, Xavier Templeton, entered the room. A tall scrawny man, Templeton had pale hairless matchstick arms that looked better hidden within a surgical gown. His bushy eyebrows met in the midline, and his left eye squeezed in an involuntary tic. Templeton’s hands wouldn’t touch Elizabeth Anderson’s skin or stomach today. His hands would control two levers on a console worthy of a spacecraft, and each move he made would be translated into the movement of a five-armed machine named the Michelangelo III, also known as The Bricklayer.

The five slender mechanical arms of The Bricklayer, dull gunmetal gray in color, dangled like the legs of a giant spider above Elizabeth Anderson’s abdomen. Each arm was draped in clear plastic to keep The Bricklayer sterile when it entered her body through tiny incisions.

Alec accepted his role of goaltender at the Pearly Gates. His assignment was to keep Elizabeth Anderson asleep and alive, while Templeton and The Bricklayer resected her tumor.

Twenty minutes into the surgery, Xavier Templeton sat on a chair in the corner of the room with his back to the operating table, and peered into a binocular stereo viewer. His hands maneuvered two levers on the console before him. On the operating table, the five robot arms reached into the abdomen though five one-centimeter incisions. One of the arms held a camera on a thin metal rod, movable at the surgeon’s control. A seventh-year resident worked as a surgical assistant, and attached appropriate operating instruments to the other 18-inch-long robot arms.

The two surgeons murmured to each other in quiet voices. Alec watched the surgery on a large flat screen video monitor that hung above him. He saw pink tissues, robot fingers moving, and a lot of irrigating and blunt dissection. The surgery was going well, and Alec made only minor adjustments in his drug doses and equipment as needed.

Then one thing changed.

One of the robot fingers on the video screen convulsed in staccato side-to-side slicing movements of its razor-sharp tip. A clear plastic suction tube exiting from the patient’s abdomen lurched and became an artery of bright red blood. The scarlet tube emptied into a bottle two feet in front of Alec. In sixty seconds the three-liter bottle was full of blood. Fifty-eight seconds prior to that, Alec was on his feet and both hands were moving. A flip of a switch sent a stream of fluid through the biggest IV into the patient. He turned off all the anesthesia gases and intravenous anesthetic medications.

“Big time bleeding, Dr. Templeton,” Alec shouted to the surgeon.

As fast as he could infuse fluid into two IVs, Alec could not keep up with the blood loss draining into the suction tube. The blood pressure went from normal to zero, and a cacophony of alarms sounded from the anesthesia monitoring system.

Templeton descended from his perch on the far side of the room, and put on a sterile gown and gloves. He took a scalpel from the scrub tech, and in one long stroke made an incision down the midline of the abdomen from the lower end of the breastbone to the pubic bone. With two additional long swipes, the left and right sides of Elizabeth Anderson parted. A red sea rose between them. The surgical resident and the scrub tech held suction catheters in the abdomen, but the stream of blood bubbled upward past the catheters. Templeton cursed and reached his right hand deep to the posterior surface of the abdominal cavity, feeling for the blood vessel on the left side of the spinal column. He found it, and squeezed the empty and pulseless aorta.

Alec looked at the monitors. The blood pressure was zero, and the electrocardiogram showed the heart was whipping along at a rate of 170 beats per minute. His patient had one foot in the grave. “Have you got control up there?” he screamed at Templeton.

“God damn it! I’m squeezing the aorta between my fingers,” Templeton answered. “As soon as I can see, I’ll put a clamp on the vessel. The bleeding is everywhere. I can’t see a damn thing.” Templeton’s face, mask, hat, and gown were drenched with the blood of Elizabeth Anderson. His unibrow was a red and black dotted line.

“Fire up the Maytag,” Alec said to Maggie. “Call the blood bank and activate the massive transfusion protocol.” Alec bent over the Maytag, a rapid blood infusion device with a bowl the size of a small washing machine. He turned the Maytag to its top flow rate. The machine hummed and spun, and the basin of IV fluid emptied into Elizabeth Anderson through a hose as wide as a small hot dog.

Despite the infusion of fluid, her blood pressure peaked at a dismal 65/40. “Have you found the hole yet?” he said to Templeton.

“Torn aorta. There are multiple holes—the aorta’s leaking like a sprinkler hose,” Templeton said without looking up. His left eye was blinking and squeezing repeatedly as he worked. “It’s terrible. The inferior vena cava is shredded and the blood from the lower half of her body is pouring out into her abdomen. The blood is everywhere.” Blink, squeeze. “Her vessels are falling apart like tissue paper.”

An orderly ran into the operating room carrying a red plastic beer cooler. Alec grabbed the cooler and popped off the top. Inside were six units of packed red blood cells, six units of fresh frozen plasma, and six units of platelets from the blood bank. “Check all the units and let’s get them flowing,” he said to Maggie.

Maggie picked up each bag and double-checked the patient’s name and the unit numbers with a second nurse, and then she handed the entire cooler to Alec. He drained each of the units of blood products into the basin of the Maytag, and the bowl hummed and pumped the blood into Elizabeth Anderson. The blood pressure began to climb, but one look at the crimson suction tubes exiting the patient’s stomach told Alec they were still in trouble. The bleeding wasn’t slowing. Blood was exiting faster than he could pump it in.

“We need a second cooler of blood products stat!” he said. Maggie picked up a telephone and relayed the order to the blood bank.

Alec looked at the surgical field, and the patient’s blood was everywhere—on Templeton’s face, hands, gown, on the surgical drapes and on the floor. It was everywhere but where it needed to be—inside her blood vessels. Templeton’s resident was jamming a suction catheter into the abdomen next to Templeton’s fingers, trying to salvage as much blood as he could.

“Damn it,” Templeton said. “She’s still bleeding, and now she’s bleeding pink piss water. I can see through her blood, it’s so dilute. How much fluid have you given her?”

“Six units of blood, six units of plasma, six units of platelets, and eight liters of saline.”

Alec glanced at the monitors and saw that her blood pressure had plateaued at a near-lethal level of 40/15.

“Her blood isn’t clotting anymore,” Templeton said. “The blood’s oozing and leaking everywhere I place a suture.”

Alec palpated her neck, and there was no pulse. “She has no blood pressure and no pulse,” he said. “We need to start CPR.”

Templeton’s resident placed the palms of his hands on Elizabeth Anderson’s breastbone and began chest compressions. The patient’s heart rate of 180 beats per minute slowed to 40 beats per minute, with premature beats and pauses between them. After twenty seconds of a slow irregular rhythm, her heartbeat tracing faded into the quivering line diagnostic of ventricular fibrillation.

Alec injected 1 milligram of epinephrine, and screamed, “Bring in the defibrillator.”

A second nurse pushed the defibrillator unit up to the operating room table. Templeton charged the paddles, applied them to the patient’s chest, and pushed the buttons. Elizabeth Anderson’s body leapt into the air as the shock of electrical energy depolarized every muscle of her body. All eyes turned to the ECG rhythm, and it was worse than ever.

Flat line.

“Damn it. Give me the scalpel back,” Templeton said. He carved a long incision between the ribs on the left side of Elizabeth Anderson’s chest, and inserted his hand into her thorax.

“I have her heart in my hand and I’m giving her direct cardiac massage,” he said. Alec looked at the monitors, and the direct squeezing of the heart was doing nothing. The blood pressure was still zero, and now blood was oozing from the skin around her IV sites, as well as from the surgical wounds in her abdomen.

Elizabeth Anderson’s heart was empty. Her blood vessels were empty. Her blood pressure had been near-zero for twenty-five minutes.

“What do you think, sir, should we call it?” Templeton’s resident said.

Templeton pulled his hand out of Elizabeth Anderson’s chest, and looked at the clock. “I pronounce her dead, as of 8:48 a.m. Damn, damn, damn it!”

Alec reached over and turned off the ventilator. The mechanical breathing ceased, and there was nothing left to do. He looked down at Elizabeth Anderson’s bloated face. Two strips of clear plastic tape held her eyes fastened shut, and her cheeks were as white as the bed sheet she rested on. A length of pink tape held the breathing tube fixed to her upper lip, and blood oozed from her nose and from the membranes between her teeth. This lady walked into the University of Silicon Valley Medical Center today hoping for a surgical miracle, and instead she was going to the morgue looking like this.

Xavier Templeton peeled his gloves off. “Goddamn it! The fricking robot went berserk. Sliced into the artery like a goddamned hedge trimmer. Now I have to tell the family she’s dead. Goddamn damn it!” He scowled in Alec’s direction. “Are you coming with me, Dr. Lucas?”

Alec nodded a yes. He looked at the gloomy outline of The Bricklayer’s arms, and then back at Templeton. Templeton was a fool to blame the medical device for his own ineptitude. The machine could do no wrong on its own.

This was the surgeon’s fault. Alec had heard it all before. Accept compliments and deflect all blame—it was an adage as old as the profession of surgery.

Templeton commanded The Bricklayer. And The Bricklayer was no better than the human hands that led it.

*

*

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