Робин Кук: Charlatans

“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.