that lacked definition but I knew to be oppressive.
The patient’s blood pressure dropped into the mid-70s systolic.
“How did you check her central line pressure?” I asked Nurse A.
Behaving as if insulted by my question, Nurse A shook his head while
turning the stopcock that shifted the central line from intravenous access mode to pressure monitoring mode. The waveform signature of the patient’s heart showed up on the screen along with the number 10 at the
side. “See, I told you,” he said.
I inspected the waveform and saw the problem. A central line wave-
form has several components, each component reflecting the action of the
heart during a single heartbeat. True, the number at the side read 10,
which is slightly above normal, but that number was the average of a very
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C H A P T E R 4
low number, reflecting the true filling pressure of the patient’s heart, and a very high number, reflecting an artifact caused by the patient’s incompetent tricuspid valve. Nurse A had failed to inspect the waveform closely or, more likely, didn’t know the waveform’s different components. He
had simply taken the average number as gospel.
“She’s bleeding. Her real central pressure is 1,” I insisted.
“We didn’t lose that much blood,” the surgeon muttered to himself.
But the warning whisper of sober reason had begun to counsel him. We
all stared at the patient’s abdominal wall. It had grown tighter during our short debate. The patient was bleeding internally.
Everyone sprang into action. The surgeon sliced through his suture
line and inserted his sucker. Blood poured into the canister, sending great foaming breakers against its plastic walls. An ominous alarm on the blood pressure monitor rang. The patient’s pressure had dropped to 60/35.
I injected a cardiac stimulant into the patient’s central line. Her pres-
sure rose to 85/50. But this slight movement upward was like an engine
that had slowly risen up a long and steep ascent and was standing at the
top, waiting for some master force to propel it forward and downward
with irresistible force. Blood kept streaming out of the wound. The blood pressure monitor sent its alarming cries throughout the room. 81/49. 72/
38. 61/21. We were going to crash.
During a crisis, everyone in an operating room begins to view life
from a singular angle. The minds of all are suddenly concentrated and
their bodies efficiently perform their assigned tasks. The surgeon worked furiously, sucking, cauterizing, and stitching. The operating room nurse
called the blood bank and demanded that blood be made available for
immediate pickup. The orderly raced over to get it. In three minutes, he
dashed back into the operating room, panting heavily, as though fleeing
an enemy, carrying a large white box with a red cross emblazoned on
each side. Nurse A and I worked to place a second intravenous line in
preparation for the massive blood transfusion.
Once the initial pool of lost blood was evacuated from the abdominal
cavity, blood oozed more slowly from the patient’s bowel. But somehow,
somewhere, it found vent; it spirited up in a thick dark stream, submerg-
ing the intestines again. Looking for holes under such conditions is like trying to spot coins under murky water. Had the torn vessels been arteries, the job would have been easier, as arterial blood spurts and pulses
with great force, leaving an obvious trail back to any vessel opening. But
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the operation had rent mostly veins, and each time the surgeon scooped
out a handful of blood to look for vessel tears, another handful welled up out of nowhere and flooded the field. The surgeon could not find all the
holes.
The patient’s pulse was now barely palpable. Her white face was
suffused with a blue tinge, her eyes rested wearily in their sockets, the lines underneath them darkened funereally. The process of disintegration
had begun; the whole framework of the patient’s existence had suddenly,
in the twinkling of an eye, become a faded, shadowy thing.
Nurse A and I transfused the first round of blood products. I noticed
the surgeon breathing heavily like a wounded animal, his body heat waft-
ing upward toward the low ceiling. The patient’s bleeding remained un-
controlled. I shot a glance at the monitors. No blood pressure was mea-
surable. I expected the laws of nature to assert themselves any second,
and for the patient’s heart to give out too. Yet the EKG showed the
patient’s heart was still beating. The pacemaker had kicked in. Her heart was no different from a busted watch that keeps ticking by virtue of its
battery. I injected epinephrine into the patient’s intravenous to constrict her blood vessels and give her some semblance of a blood pressure.
Thirty seconds later, 35/15 flashed on the screen.
The surgeon furiously sutured and cauterized. Nurse A and I squeezed
four more rounds of blood products into the patient’s bloodstream.
Her blood pressure rose steadily: 50/27. 68/44. 81/51. The surgeon
grew less frantic. We were on an upward path. Thirty minutes later the
patient was stable.
Such a right-about-face of destiny is common in anesthesiology. The
patient’s course moves swiftly toward disaster; then suddenly things are
well again, a mischance prevented, a horrible outcome forestalled. Life,
which suddenly seemed on the verge of being lost forever, belongs to the
patient once more. But what brain damage the patient had suffered during
the period of absent blood pressure we did not know. The surgeon re-
sutured the abdominal wall. We hoisted the patient’s bony body onto the
stretcher and moved her to the intensive care unit.
I removed the breathing tube a day later. The patient suffered some
weakness on her left side. She strengthened over the next week. After a
month, she regained all of her function.
Who was responsible for this near catastrophe? The surgeon? After
all, the surgeon had caused the bleeding. Yet if the patient’s tissues were
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inherently friable and prone to oozing, no one could blame the surgeon
for the blood loss that inevitably followed. Me? True, if I had done the
case on my own, I might have noticed the drop in central venous pressure
earlier. But a doctor today inevitably works with subordinates, and those subordinates must be free to make decisions. Indeed, subordinates rebel if not allowed such freedom. A doctor with experience knows that it is both
impossible and counterproductive to micromanage the activities of every
subordinate. A supervising doctor shapes the general direction of the case or points out certain general trends. The traffic officer regulates the flow of traffic; he or she does not assign a particular course to each car.
Nurse A? Closer. If Nurse A had alerted me to the drop in blood
pressure before things had gotten out of hand, the catastrophe might have been averted. But that simply begs the question of why he had not. For
that we must blame the medical profession.
Nurse A had internalized professional medicine’s definition of the
doctor as a master technician. Because Nurse A was technically accom-
plished, he grew cocky. Having mastered what he believed to be a doc-
tor’s core duties, it was only natura
l that he would imagine his capacity for doctoring to extend into other areas—such as managing the patient’s
sagging blood pressure on his own rather than alerting his attending. How doctors define themselves had initiated a cascade of events that almost
led to a catastrophe.
It also explains why my first nurse anesthetist was so ill natured and
intractable. She resented the salary differential between her and me—and
naturally so, for if the medical profession tells her that a good doctor is a good technician, and she is a good technician, then all that separates them is salary, which to her mind is arbitrary and unfair. BSN, MSN’s behavior was rooted in similar thinking. She saw doctors as her masters, and she
liked being paid by her masters, but she wondered why she ought not to
become a master herself, especially since well-trained nurses can insert
needles and prescribe pills as well as any doctor can. Hence, the idea of
“team medicine.”
I encountered a variation on this attitude a month before writing this
chapter. I was traveling on the highway. A car had crashed ahead of me.
A paramedic truck was parked beside it. I stopped, got out of my car,
leaned over the crash victim, told the paramedics I was a doctor, and
offered to help. Rather than welcome my assistance, the two paramedics
at the victim’s side ignored it. One paramedic, with a scowl, asked me
W H E N N O O N E I S I N C O M M A N D
7 5
what kind of doctor I was. I told him I was an anesthesiologist. As the
patient’s face dripped blood, the paramedic shrugged and said, “I’ve
probably seen a lot more trauma cases than you.” His purpose at that
moment was not to help the crash victim, but to make the point that here, in the field, he was more of a doctor than I was.
Nurses may protest. They will say I have generalized from a few bad
apples to condemn all nurses. That is not my purpose. Moreover, any
such generalization would be grossly inaccurate. Like most doctors, most
nurses are hardworking professionals with a sense of balance about what
they do and do not know. They take good care of their patients. They are
knowledgeable and bring a wealth of experience to patient care. It is no
surprise that the safest format for practicing anesthesia remains an an-
esthesiologist and nurse anesthetist working together, thereby doubling
the trained set of eyes and ears around a patient. Doctors and nurses were practicing team medicine long before “team medicine” became a political
cause, a catch phrase, and a movement. Few nurses are like BSN, MSN or
Nurse A.
But neither are there many catastrophes. I would be remiss if I didn’t
place the correct interpretation on those few catastrophes that I have
experienced in my career to benefit the reader from the lessons and, for
that matter, the warnings they contain. We all know the ideal of the
doctor and the nurse. But in this world of dreams, are we justified in
ignoring the few nightmares?
5
WHEN PATIENTS BECOME CONSUMERS
A week later, while still new at the hospital, I was assigned to another D and C. My patient was nervous, and when she fretted that her surgery
was scheduled for a full hour, I tried to reassure her. “Don’t worry. It’s more like ten minutes,” I said.
Several days later, a senior doctor approached me with a grin on his
face. “Did you tell that patient her surgery was only ten minutes?” he
asked.
“Yes,” I replied.
The doctor laughed. “Young man, never tell patients it’s ten minutes,
even if it is. When they get the surgeon’s bill, they’ll feel swindled. ‘All that money for just ten lousy minutes!’ they’ll say. Always tell them at
least thirty.”
“Welcome to private practice,” I joked sheepishly.
“Don’t worry, you’ll learn, but the surgeon is mad because his patient
thinks she’s been cheated,” he replied.
Most doctors learn at some point that satisfying patients involves more
than just curing them of disease. Patients always feel a little vulnerable in a doctor’s presence. Nakedness threatens their self-respect; a physician’s superior knowledge threatens their self-confidence; patients who would
not ordinarily admit their weaknesses suddenly find themselves forced to
discuss their most intimate problems, embarrassing them. Then there’s
the doctor’s bill. On top of that, patients worry about being hurt with
scalpels and needles. And, of course, there is the fear of dying. A curiosity in medicine is that upon disease—a very natural phenomenon—the
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most exquisitely complex emotional states are erected. For this reason
doctors learn to treat patients somewhat gingerly and to accept their un-
reasoning sides. Nothing is stupider than the doctor who, from scientific or doctrinaire heights, is contemptuous of a patient’s funny feelings and ideas.
Nevertheless, the doctor-patient relationship is an inherently unequal
one, and the unreasonable patient who tries to make it equal—for exam-
ple, by telling a doctor how to practice medicine—risks complications,
even catastrophes. One might compare the impulses of a patient’s mind to
the movements of the ocean. One patient complains about his bill; a
second patient complains that his doctor gave him bad directions; a third patient complains that her doctor didn’t return her phone call. The wise
doctor never becomes exasperated by such events. Like the mariner in a
storm, he or she slackens sail, waits, and hopes; eventually, the storm
passes and the voyage continues. But a patient who demands to be on
equal footing with his or her doctor creates the conditions of a permanent storm, making travel dangerous.
I encountered this problem during my second month in practice when
caring for a doctor’s wife scheduled for a vaginal hysterectomy. I anticipated trouble upon greeting the woman in the pre-op area. I spied her
coiffed hair and exact lipstick. Her wrists and fingers were adorned with gold. Her whole presentation seemed astonishingly expensive and well
ordered, and out of place for a surgical theater. In those days being a
doctor’s wife meant something, and this woman wanted everyone to
know she was no ordinary patient.
I told her it would be best if she wiped off her lipstick. She refused.
“All right, can you remove the nail polish from just one finger?” I
asked.
“Why are you insisting on this?” she asked with inexplicable pride.
“Are you always so rude to your patients? Or maybe you just don’t like
the color.”
I knew what was going on. The source of her stubbornness was not in
me but within herself. The woman felt vulnerable, and understandably so.
She needed surgery on a bodily area that, to her mind, defined woman-
hood; she was scared and embarrassed; even her flirtatiousness sprung
from fear. If a doctor analyzes looks, words, and gestures, and is open to hidden meanings, he or she can usually explain the rough treatment he or
she is getting from a patient.
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But this woman was interfering with my ability to take care of her. I
told her I had to be able to inspect her skin color while she was und
er
anesthesia, to check for anemia or hypoxia. She continued to resist, al-
though in a sweeter tone. “Please, doctor, I’m just used to looking my
best,” she pleaded. Her emotion was a complex one, made up of pride, a
claim to delicacy, an appeal to my willingness as a man to sacrifice my
desires for a woman, and a need to establish self-assurance by winning a
difficult victory. In any other patient I would have insisted on the fingernail polish (and the lipstick) coming off, but since she was a doctor’s wife and a special case, I relented.
The nurses also relented by letting her keep her jewelry on. Indeed, the
whole operating team was on edge because of her VIP status. They scur-
ried around to create an exceptional surgical experience for her, an experience that fit her so well that it seemed as though the best doctors in the city had consulted among themselves how to proceed in the best possible
fashion. When the woman arrived in the operating room one nurse fussed
about her, putting a pillow under her head as she lay down. Another nurse stood at her side and held her hand. Lying on the table, her gown unwrinkled, her bracelets and rings shining exquisitely under the light, her body unruffled and still, the woman looked as if she had been chiseled into
marble, the work of a brilliant sculptor—the perfect beginning to a per-
fect operation. And yet one of the nurses forgot to give her an antibiotic.
I gave the woman some narcotic and Versed. Rather than fall silent,
she grew talkative. She confessed to having crush on the surgeon. The
surgeon’s eyes smiled at me; then he nodded his head—my cue to put the
patient to sleep quickly before she said anything more embarrassing.
I would be remiss in writing a book about anesthesiology, even a
serious book about anesthesiology and medical safety, without answering
the question I am asked most often about the field: Do people talk under
anesthesia, and, if so, do they ever talk about sex? Now would be a good
a time to answer this question. Yes, people under anesthesia do talk about sex. In my experience, and in the experience of other anesthesiologists
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