Robin Cook: Host

“Good morning, Mr. Vandermeer,” Sandra said. “I’m Dr. Wykoff, I will be your anesthesiologist.”

“I want to be asleep!” Carl stated with as much authority as he could muster under the circumstances. “I went over this with Dr. Weaver, and he promised me that I would be asleep. I don’t want an epidural.”

“No problem,” Sandra said. “We’re all prepared. I understand you are a little anxious.”

Carl gave a short, mirthless laugh. “I think that is an understatement.”

“We can help you, but it does require me to give you an injection. I know you don’t like needles, but are you okay with getting one? It will help, I guarantee.”

“To be truthful, I’m not excited about it. Where will you give it?”

“Your arm will be fine.”

Steeling himself, Carl dutifully exposed his left arm and looked away to avoid seeing the syringe. After a quick swipe with an antiseptic wipe, Sandra gave the injection.

Carl turned back. “That was easy. Are you finished already?”

“All done! Now I want to go over with you the material the admitting nurse recorded.”

Rapidly Sandra asked the same questions about Carl not having had anything to eat since midnight, about allergies, about drug intolerance, about medical problems, about previous anesthesia, about removable dentures, on and on. By the time Sandra got to the end, Carl’s attitude had completely changed, thanks to the midazolam. Not only was he no longer anxious, he was now finding the whole situation entertaining.

At that point, Sandra started her IV. Carl couldn’t have cared less and watched her preparations with a sense of detachment. It helped that she was extremely confident and competent with the procedure. She always made a point to start her own so she could trust it. She used an indwelling catheter rather than a simple IV. Carl never stopped talking through the process, particularly about his girlfriend, Lynn Peirce, who he said was a fourth-year medical student and the best-looking woman in her class. Sandra diplomatically let the issue drop.

A few minutes later Dr. Gordon Weaver appeared to have a few words with Carl, including which knee they were going to work on. He checked that the X that the admitting nurse had made with the permanent marker was on the proper thigh.

“You people are really hung up on which knee,” Carl joked.

“You better believe it, my friend,” Dr. Weaver said.

With Sandra guiding in the front and Dr. Weaver pushing from the back, they wheeled Carl down and into OR 12, stopping alongside the operating table directly under the operating room light. Somewhere en route Carl had drifted off into light sleep in midsentence, again reminding Sandra why she was so fond of the midazolam. Only much later would Sandra question the dose she had given in the process of reviewing everything she had done. Sandra, Dr. Weaver, and Claire Beauregard moved Carl over onto the operating table with practiced efficiency.

When Dr. Weaver went out to scrub, Sandra pulled the anesthesia machine close to Carl’s head. This was the part of the case that she liked the best. She was center stage and about to prove once again the validity of the science of pharmacology. Anesthesia was a specialty marked by extreme attention to detail; periods of intensive activity, like what she was now beginning; and then long segments of relative boredom, which required dedicated effort to stay focused. Whenever she thought about it, the analogy of being a pilot came to mind. At the moment she was about to take off. After that had been accomplished she would be in the equivalent of midflight autopilot and have little to do besides scanning the monitor and the gauges. It wouldn’t be until the landing that she’d again be called upon for intense activity and attention to detail.

Since there were no specific contraindications to any of the current anesthetic agents, she planned on using isoflurane, supplemented with nitrous oxide and oxygen. She had used the combination in thousands of cases and felt comfortable with it. There was no need for any paralyzing drugs because a knee operation didn’t require any muscular relaxation like with an abdominal operation, and she wasn’t going to use an endotracheal tube. Instead she would use what was known as a laryngeal mask airway, or LMA. Sandra was a stickler for detail in all aspects of her life but most specifically for anesthesia, and had never had a major complication.

Like all anesthetists who are specially trained nurses and anesthesiologists who are specially trained doctors, Sandra knew that the ideal anesthetic gas should be nonflammable, should be soluble in fat to facilitate going into the brain, but not too soluble in blood so that it could be reversed quickly, should have as little as possible toxicity to various organs, and should not be an irritant to breathing passageways. She also knew that no current anesthetic agent perfectly fulfilled all these criteria. Yet the combination she intended to use with Carl came close.

The first thing that Sandra did was to set up all the patient monitoring so that she would have a constant readout of Carl’s pulse, ECG, blood oxygen saturation, body temperature, and blood pressure, both systolic and diastolic. The anesthesia machine would monitor the rest of the levels that needed to be watched, such as oxygen and carbon dioxide levels in inspired and expired gases and ventilation supply variables.

As Sandra positioned the monitors, particularly the ECG leads and the blood pressure cuff, Carl became conscious. There was no anxiety on his part. He even joked that with everyone wearing masks it was like being at a Halloween party.

“I’m going to give you some oxygen,” Sandra said as she gently placed the black breathing mask over Carl’s nose and mouth. “Then I will be putting you asleep.” Patients liked that comfortable metaphor rather than what Sandra knew anesthesia really to be: essentially being poisoned under controlled and reversible circumstances.

Carl didn’t complain and closed his eyes.

At that point Sandra injected the propofol, a fabulous drug in her estimation that was unfortunately made infamous by the Michael Jackson tragedy. Knowing what propofol did to arterial blood pressure, ventilation drive, and cerebral hemodynamics, Sandra would never give the drug to someone without appropriate physiologic monitors and a primed and ready anesthesia machine.

In the induction phase, Sandra was now in her most attentive mode. With an eagle eye on all the monitors she continued to use the black breathing mask to allow Carl to breathe pure oxygen. In the background she was vaguely aware of Dr. Weaver coming into the room and putting on his sterile gown and gloves. After approximately five minutes, Sandra put the breathing mask aside and picked up the appropriately sized LMA. In a practiced fashion she inserted the triangular, inflatable tip into Carl’s mouth and pushed it into place with her middle finger. Quickly she inflated the tube’s cuff and attached the tube from the anesthesia machine. The immediate detection of carbon dioxide by the anesthesia machine in the exhaled gas suggested the LMA was properly seated. But to be sure, Sandra listened to breath sounds with her stethoscope. Satisfied, she taped the LMA tube to Carl’s cheek so that it could not be moved. She then dialed in the proper levels of isoflurane, nitrous oxide, and oxygen. The nitrous oxide had some anesthetic properties but not enough to be used on its own. What it did do was lessen the amount of isoflurane needed, which was helpful, because the isoflurane did have some mild irritant effects on breathing passageways. She then taped Carl’s eyes shut after putting in a bit of antibiotic ointment to protect his corneas from drying.

Sandra watched the anesthesia machine with its readout of all the vital signs. Everything was in order. The takeoff had been smooth. Metaphorically they were nearing cruising altitude and soon the seat belt sign could go off. Sandra’s pulse, which had jumped considerably during the induction of anesthesia, dropped back to normal. It had been a tense few minutes, as it always was, yet it provided her a shot of euphoria of a job well done and a patient well served.