ADRENALINE: New 2013 edition (10 page)

They both ordered chicken salad sandwiches, the specialty of the coffee shop, at Dr. Landry’s suggestion. After their orders were filled, the two men took seats at a small table in the back of the noisy, crowded room.

“So Rusty, which specialty are you thinking of?”

“I’m not really sure yet, but I guess I’m leaning toward cardiology or internal medicine,” Rusty said as he proceeded to wolf down his chicken salad sandwich. “Mmm, this is good,” he managed to get out between considerable bites.

“Medicine? Yuck, kinda boring,” Dr. Landry replied, also munching away.

“What made you choose anesthesia?” asked Rusty. “Do you like it?” Normally, Rusty would never have asked an attending such a personal question, but with Dr. Landry it seemed okay to push it.

“Yeah, I do like it. Not many people have a good feel for what it’s really all about, though. Even after my rotation through it my third year—two weeks, just like you—I didn’t have much of a clue. Seemed dull just watching these people sleep, but I liked all the computer and chemistry stuff. So I took a month of it early fourth year and loved it. I’ve always liked doing procedures and always disliked having long discussions with patients about their aches and pains.”

“Yeah, I know what you mean. How long have you been here?”

“About twelve years.”

“Wow,” Rusty said and meant it. “I hear Doctor Marshall and Doctor Raskin have been here since the place opened.”

“Pretty much.”

“Do you think I’ll get the chance to work with Doctor Marshall?”

Dr. Landry smiled wryly and said, “I’m sure you will.”

Rusty decided to switch gears. “How’s the job situation in anesthesia?”

“Not so good, Rusty. With all the mergers, managed care pressures, and Medicare cuts, the job situation is tight. Some people are desperate just to keep their jobs.” Dr. Landry said it in a funny way, like he knew more than he was saying. “But for good people, opportunities always exist.”

“But still, don’t you find it boring?” Rusty asked. “You know in
The House of God
, he says anesthesia is ninety-nine percent boredom and one percent sheer terror.”

“That guy was obviously never an anesthesiologist. It may look easy watching someone skilled do it, but let me tell you something, Rusty. When they walk out of the room the first time and you’re alone with the patient—it ceases to become boring real quick. When you realize it’s just you, your hands and brain, between a deadly arsenal of drugs and a patient’s life, it’s very sobering.”

Rusty raised his eyebrows and murmured, “Hmmm.” His mouth was too full to speak. Out of the corner of his eye, Rusty noticed several nursing students who had just come in and were standing in line. One in particular, a tall brunette with shiny white stockings, seemed to be looking right at him and smiling. Rusty returned the smile, but then quickly forced himself back to the conversation. Can’t appear rude to Dr. Landry. Medicine required sacrifices, and this was one of them.

Rusty looked at Dr. Landry, expecting him to be in mid-sentence or frowning at him. But, he noticed that Dr. Landry was also staring off in the direction of the stockings, and hadn’t said anything. Amazing, thought Rusty. He knew from talking to Dr. Danowski that Landry was married with several children. He seemed good-looking enough, although Rusty felt he was a poor judge of these things. But, the thought of him checking out the nurses amused Rusty. Why, he must be over forty! “Very sobering,” Rusty said.

Dr. Landry shook his head, smiled quickly, and resumed eye contact with Rusty. “I’ll never forget the day I soloed. My attending was just ten feet outside the OR door looking in and I was still scared shitless. What if the patient goes brady, loses pressure, or bleeds too much? What if I can’t ventilate, or intubate, or get laryngospasm? A million what-ifs go through your head, and you try to figure if you know how to treat each one fast enough. Don’t let the boredom part fool you.” He shook his head.

“Hmmm, you make it sound kinda scary or dangerous. But Dr. Landry—”

“It’s Doug, Rusty.”

“OK, don’t you think surgery is a lot scarier? After all, they’re doing the real cutting.” Rusty couldn’t help but notice the brunette and her friends had occupied a nearby table. He smiled in their direction.

“No way. It’s a very popular misconception, though. Now I’ll grant you that some branches of surgery, like CT or major vascular, are very demanding . . .”

“CT?”

“Cardiothoracic. And I don’t mean to make their job sound easy. It’s not. I’m not sure I’d ever want to do it. But, consider the bread-and-butter surgeries—the hernia repairs, the knee arthroscopies, the gallbladder removals, and so on, that make up ninety percent of all operations. The likelihood of the surgeon inflicting a mortal wound during one of these procedures is extremely remote.”

“Why do you say that?” Rusty asked.

“Well, because the area being operated on is far from any vital organ or large blood vessel,” Dr. Landry continued. “And that’s not to say all surgeons are perfect and don’t botch things up. On the contrary, mistakes do happen.”

“You mean like amputating the wrong leg or something.” Rusty thought Dr. Landry seemed a bit touchy in this area; perhaps he was jealous of the surgeons.

“Exactly,” Dr. Landry went on, “although that represents an extreme case. Sometimes hernias need refixing in several months or ear tubes fall out. The point is that the mistakes almost never cause immediate loss of life or brain damage.”

“OK, I get it. But what makes anesthesia so different?”

“Glad you asked.” Dr. Landry paused to take a bite of his sandwich. “Putting someone under a general anesthetic is completely different. Now,
every
case carries with it a small, but real risk of death or brain damage. You can die from anesthetic complications just as easily going to sleep for a five-minute D&C as you can for a five-hour spine fusion.”

“Jeez, that’s comforting. Good thing no one knows that.”

“Rusty, it doesn’t mean that being anesthetized is incredibly dangerous. It’s not. In the hands of a competent anesthesiologist, it’s very safe, carrying a risk similar to driving to the hospital. The point is that a general anesthetic involves the perfusion of all the vital organs; it’s not a peripheral procedure. Didn’t they teach you anything about perfusion in med school?”

“S-sure,” Rusty stammered, suddenly trying to buy time. “It’s, uh, means getting blood flow to the tissues.” Typical attending—they’re all alike. Just when he thought he was away from the Med Center.

“Right,” Dr. Landry said and smiled. Rusty relaxed a bit and took another bite of his rapidly disappearing sandwich. “Now what’s the purpose of having tissue blood flow?” Dr. Landry asked.

“Well, the tissues need oxygen.”

“Exactly. You
have
been paying attention in school. Oh, that reminds me of the old joke. What’s the deadliest substance known?”

“Uh, I’m not sure.”

“Oxygen, of course. It kills in levels as low as one part-per-billion.”

“Hmmm . . .” Rusty didn’t get it, but vowed to work on it later.

“Anyway, here’s the important part. What can disrupt tissue oxygen delivery or perfusion?”

“Well let’s see.” Rusty put on his best studious look as he thoughtfully sipped his Coke. “If there’s a cardiac or BP problem, not enough blood will be pumped. That’d mess up perfusion.” Rusty suddenly realized where Landry was going with this. “Or if the patient’s not breathing, his O-two intake will stop.”

“Precisely!” Dr. Landry beamed. “And this is what we deal with in anesthesia. Any airway or blood pressure problem can deprive the heart or brain of oxygen with disastrous results in minutes.”

“When we put someone to sleep, what’s the first drug we give them?”

“The white stuff, uh, Diprivan?”

“Right. Diprivan, otherwise known as propofol. They lose consciousness quickly and then they don’t breathe, so we start ventilation by mask.”

“What’s the problem?” asked Rusty.

“What if you can’t ventilate them with the mask?” Dr. Landry countered.

“Why wouldn’t you be able to? Anyway, then you could just intubate them with the endotracheal tube, right?” Rusty asked.

“Right, but you’re getting ahead of yourself. Which drug did we give next to facilitate the intubation?”

“The muscle relaxant, succinylcholine,” Rusty said.

“Very good. You’re with me. But there’s a major trap lurking here that I don’t think you’re even aware of.”

Rusty hated when he missed major traps; there were so many in medicine. He concentrated very hard trying to come up with an answer. Dr. Landry appeared to wait patiently. Finally, with some disappointment Rusty said, “OK, you’re right. I don’t see it.”

“Take it from me, there are some people you can’t mask ventilate. Usually, it’s the big ones, the three-hundred-pounders, but you never know for sure until you try, until they’re asleep.”

“So you intubate them,” Rusty replied quickly, irritated that he was still missing the point.

“You mean push the succinylcholine, paralyze them and then intubate?”

“Yeah, right.” Rusty knew he had made a mistake but wasn’t sure how yet.

“Herein lies one of the most dreaded situations in all anesthesia, my friend.” Dr. Landry paused to crunch on some chips, and took a quick look at the brunette’s table. “There are also people you can’t intubate. If you’ve just paralyzed this patient who you can’t ventilate with the mask, and now you discover you can’t intubate him, you’re screwed big time. Up the creek. Shit out of luck. You can’t breathe for him, and you just paralyzed him, so he can’t breathe for himself either.” Dr. Landry sat straight back in his chair, fiddled with his surgical cap, and looked straight at Rusty. “Get the picture?”

“Yeah, I do,” Rusty said softly as the meaning sank in. “So, like, he dies?”

“Well, hopefully not, although that’s possible. It’s emergency trach time.”

“Yeah, right. I’ve seen that on
ER
.”

“It’s not as easy as it looks, Rusty,” Dr. Landry said grimly. “By the time the shit hits the fan, and you’ve finished mucking around with your unsuccessful intubation attempts, your patient’s blue as hell and headed south fast. You probably have about one minute left to get the trach tray in the room, use it, and hook it up before he dies. Not a lot of leeway for error.” Dr. Landry wasn’t smiling anymore and looked more intense than Rusty would’ve thought possible.

“Man, this airway stuff is pretty serious,” Rusty said in a subdued tone. He quickly switched his facial expression to match that of Landry’s. “Have you ever had a patient, uh, like that. You know, you couldn’t ventilate or intubate?”

“’Fraid so and even worse.” A troubled look clouded Dr. Landry’s features.

“Did they, uh, it turn out okay?” Rusty asked tentatively.

“You be the judge. Back when I was a second-year resident, I once gave the wrong drug to a patient.”

Rusty was shocked. He couldn’t imagine Dr. Landry making a mistake; he exuded such an air of capability. And he really couldn’t imagine an attending telling him about it.

“Her name was Stephanie,” Dr. Landry said, “and she was having her first baby.” His eyes drifted as he focused inward on the memory. “She was my age at the time, and we hit it off nicely. I had just finished putting her epidural in. It worked great. She was so relieved that she couldn’t feel her contractions anymore. She gave me the sweetest smile, took my hand and shook it, and thanked me profusely. Then her BP dipped, which isn’t that uncommon. I was a little nervous and reached for the ephedrine syringe to give her BP a boost. I gave her Atracurium by mistake.” Dr. Landry’s face twisted in pain as he said this. “Do you know what Atracurium is, Rusty?”

“Yes, it’s a muscle relaxant.” Rusty felt sick as the implications of paralyzing an awake patient sank in. But, he was also fascinated. “What happened?”

“When she started gasping for air and whispering ‘I can’t breathe,’ I realized quickly enough what must’ve happened and began to try to ventilate her with a mask. I can still remember her eyes, her beautiful blue eyes wide with panic, staring up at me. I told her everything would be all right to calm her down, but I didn’t believe it. I don’t think she did either. To this day, I can’t think of anything worse than being paralyzed awake and not being able to breathe.”

“Jeez, that’s horrible.”

“Unfortunately, pregnant women don’t have the best airways and I wasn’t able to ventilate her well enough.”

“Oh, shit,” said Rusty. He felt his own heart begin to pound as he imagined himself dealing with such a situation.

“So, I tried to intubate her and guess what.” Dr. Landry wore a sad expression.

“She was a difficult intubation?”

“You got it. I realized I was in deep shit. She was turning dusky and time was running out.” Dr. Landry paused, and a frightened look gripped his face. He was obviously reliving the memory.

“Did she make it?” Rusty asked, on the edge of his seat. He had forgotten all about the brunette.

“She did, no thanks to me. The OB nurses had called the senior anesthesia resident. He came up stat and trached her while I stood by helpless and shaking.” Dr. Landry was staring at his plate, his hands playing with his napkin. Rusty wasn’t sure, but thought he could detect a slight trembling of Dr. Landry’s hands.

“Wow, that’s some story,” Rusty said and took some deep breaths. He was genuinely touched that Dr. Landry had shared this experience with him. He had never had such a discussion with an attending before.

“You don’t ever forget a case like that,” Dr. Landry said. “It goes through my mind every time I put someone to sleep. I learned a lesson that day. You can care too much for people.” He shook his head slightly and a weak smile spread across his face. Rusty thought he looked a bit embarrassed, probably he figured from baring more emotion than he liked. Dr. Landry seemed like one of those people who like to keep a tight rein on their emotions. Rusty knew the type. They projected a happy-go-lucky, go-with-the-flow attitude, but shied away from any real positive or negative swings of emotion.

The two sat there not saying anything. Dr. Landry wiped his hands on his napkin for the third time and Rusty played with the little plastic swords that had held his sandwich together. The silence quickly became uncomfortable, so Rusty said the first thing that came to his mind. “Dr. Carlucci seemed pretty upset yesterday in the locker room. Is he gonna be OK? What happened?”