Робин Кук: Charlatans

“He went into OR sixteen, where his second team is opening up his second pancreatic patient.”

“Which means he is responsible for three patients under anesthesia,” Ava said derisively.

“But Janet said he will be here in a second. She promised.”

“Where is Dr. Kumar?”

“No idea. Probably going back and forth between the two rooms. He does that sometimes.”

“Give me a break,” Ava said to herself, thinking it was a good thing the general public didn’t know this kind of thing went on in a major teaching hospital. Out of the corner of her eye she saw movement in the scrub room. Turning her head, she saw Dr. Mason putting on a surgical mask while talking and laughing with another younger man whom Ava did not recognize. Ava took a deep breath to calm herself.

Five minutes later Dr. Mason breezed into the room. “Hello, everybody,” he said with alacrity. “I want you all to say hello to Dr. Sid Andrews. He is to be my new fellow starting July first, but he generously volunteered to come in today to give me a hand with this hernia repair. It has been a while since I’ve done a hernia, so I thought it couldn’t hurt.” He laughed as if he’d just said something absurd about him needing help.

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.