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Authors: Carol Cassella

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BOOK: Oxygen
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I look at the immense whiteboard across from Bethany’s desk that displays the entire list of surgeries and operating rooms, scheduled cases in black felt-tip pen and emergencies in red. Beside the number 5 runs a list of three short cases—a mastectomy, a ventral hernia repair and a central line placement—followed by one longer pediatric surgery. The first three anesthetics should be relatively simple and straightforward, if the patients are healthy. I’ll have to talk to Don Stevenson, my surgeon, about the child. We don’t take care of children as often as adults at First Lutheran, so those cases always seem more stressful. If Don can finish his surgeries reasonably close to the predicted time, I’ll be able to move into room 8 by three o’clock and let Joe Hillary go home to sleep. But I’ve worked with Don for a long time and know his tendency to overbook his day.

I tell Beth, “Better get a backup for Joe. Stevenson will run late, which will push that last case past three, I bet. Who’s on General Surgery call today?”


“Oh God. Marconi. We’ll all be here late.” Sean Marconi is famous for working all night. Even on fourth call I am at risk for a long day.

Bethany winks at me over her glasses. “God
or God

“Does Marconi know the difference?” She laughs and I add, “You never heard me say that, Bethany. We have enough gods here as it is.”


Room 5
is at the end of a branching hallway off a central core of equipment storage rooms. The clink of metal and plastic echoes off the tile walls with every footstep; I sound like a fully equipped security guard with my stethoscope and keys dangling around my neck, my pager and cell phone clipped to my waist, pockets stuffed with pens and vials of medicine and syringes. The sky would just now be lightening, if I could see it. I sometimes spend entire days without sunrise or sunset, moving from windowless operating rooms through interior hallways to a windowless cafeteria.

An operation is already under way in room 8; Joe Hillary is hunched over the small desk attached to his anesthesia machine, papers lit by a narrow beam of light in an otherwise darkened room. I grab a surgical mask from the shelf above the scrub sink and tie it over my mouth and nose, then push open the heavy steel doors, wide enough to wheel an operating table through. The surgeon looks up and nods, but Joe doesn’t see me until I’m nearly beside him. His patient is sleeping, her eyes carefully taped shut to prevent any corneal scratches, a plastic endotracheal tube jutting from her mouth. The tube rhythmically fogs and clears with each cycle of the ventilator. Beyond the blue drape that separates us from the surgical field, television cameras display the inside of her abdomen, inflated to the size of a pumpkin with carbon dioxide so the organs can be seen and dissected. The pale oranges, deep purples and soft yellows of her tissues, crisscrossed by a netting of red vessels, shift on the screen each time the camera moves. The surgeon teases her swollen gallbladder away from her liver and her blood pressure climbs. Joe, sitting near her head, turns his anesthesia gas up in response. Anesthesia is not a static thing, any more than human beings are static. The soup of drugs and gases needed by each patient is unique, modified throughout the course of surgery.

I lean close to his ear so our conversation won’t distract the surgeon. “Hey. Why are you doing a chole at this hour?”

“You see the board? The schedule was too full to add her on later today.”

“Fielding’s got two sitting craniotomies. I love those cases. I should ask Bethany to put me in neuro more often.” The ventilator thrums in a slow drumbeat, whole notes below the high-pitched quarter notes of the patient’s pulse. “It’s freezing in here. Want me to turn up the thermostat?” I pick up a blanket lying next to Joe’s chair and wrap it around my shoulders.

He shakes his head. “Keeps me awake.” He is slumped on his high stool so that, despite his height, our faces are level. I can only see his eyes, bracketed between his surgical mask and hat, blushed with fatigue. “Did you get any sleep?”

He shakes his head. “Goddamn pager went off every time I put my key in the call room door.”

I massage his neck for a minute. Joe likes to work hard—work hard and play hard. We both chose First Lutheran because of its reputation as the best of the multiple hospitals that crowd this area of Seattle. The cords of his shoulders and spine are taut.

“Why don’t you go get a cup of coffee?” I offer.

“Don’t worry about it. You’ve got your own cases to start.”

“Go on.” I nudge his side and, when he still doesn’t move, rub my knuckles under his rib until he laughs and pulls away. “Take a break. My first case is an easy setup.”

He finally gets up from the stool, stretching and peeling off his latex gloves as he gives me a quick summary of the woman’s health history and her current status under anesthesia. I fill in the few vital signs that the machines have automatically measured over the last few minutes and sign the chart.

Joe comes back in under ten minutes, looking slightly less beaten down by the night, an aroma of coffee and mint on his breath. Clear droplets of water are beaded through his sideburns, eyebrows and across his forehead, and the front of his scrub top is splotched with dampness.

“Thanks,” he says. “If I get out of here before sundown I’ll pay you back.”

“Save it. Pay me back next week. Gary and his daughter are flying into town for a visit and I might need to trade a day with you.”

He raises his eyebrows. “So, I finally get to meet your ex?” Gary and I shared a house—completely platonically—with two other women when I was in medical school and he was a business major at the University of Houston. He’s still a dear friend. Joe refers to it as my time in the commune.

I jab at his ribs again; this time I laugh, and the surgical technician looks up at us. I give her a tiny wave, turn away from the field and lower my voice. “Let’s all go to Wild Ginger one night. But don’t use that joke in front of his daughter—her mother might not find it very funny if it got repeated. I can’t believe he’s the father of a thirteen-year-old already.”

“Does she look like you?” he asks in a wheedling tease.

“No jokes, Joe. Promise, or you don’t get to meet him.” I pick my pen up from the desk and drop the blanket across Joe’s neck. “Gotta go. I’ll be back as soon as Stevenson finishes up.”

Joe is my best friend at First Lutheran. More specifically, he is my best friend. And for a few months, years ago, he was also my lover.

I knew better. Since medical school I’d drawn an ironclad curtain between my work and my love life, unwilling to offer up my private world as locker room entertainment for my peers. Operating rooms breed close friendships, but they can also be dens of gossip and slippery personal boundaries. Something about the collusion of working for hours together in these semisealed vaults of technological marvel and conceit, clustering around our patients like flesh-colored components of a great and mysterious machine, mass-producing kidney transplants and knee replacements and breast biopsies and rotator cuff repairs. It’s like belonging to a secret society in which we all check our fallibility at the door in order to muster the utter gall to play gods over disease.

I consciously reminded myself of this when I recognized the tinge of nervousness I felt if he sat next to me in the conference room, the awkward awareness of my posture and the sound of my voice. Now I think the months of forestalling that came before the giving in may be the reason we have such a strong friendship, as if the sexual love between us had been an island in the middle of four years of mutual confidences and inside jokes and shared stamina over long workdays. It’s almost as if that island of physical intimacy had bonded us, like the blood pacts I’d made with girlhood friends.


Anesthesia is like aviation—we have backups for our backups, safety nets stashed along the route. Only the human link in the chain comes without an installed flashing red light. By 6:15
, I am in room 5 setting up my work space and anesthesia machine—a ritualized check of vacuums, pumps, pressurized tubing, gas flows, monitors, warning lights, emergency drugs and alarms. The blaring tones and beeps sound like an out-of-tune orchestra warming up.

A red cart with multiple locked drawers holds my breathing tubes, IV lines, syringes, suction catheters, laryngoscopes for seeing the tiny passageway to the lungs through the caverns of the mouth and throat—all the myriad equipment I need to drift my patients safely into the timeless void of anesthesia. The top drawer holds drugs: drugs that obliterate consciousness and memory, drugs that paralyze muscles and then restore them to strength. I have drugs that raise or lower the heart rate, manipulate blood pressure, thin the blood, numb the skin, empty the stomach, slow salivation. On top of my cart is a small locked box holding my narcotics—morphine, Demerol, fentanyl, Dilaudid—the miracle drugs that make surgical pain bearable. Invisible chemicals, clear as water, the cousins and stepchildren of opium. Injected into the bloodstream, they seep into the brain to bind and block the molecular keyhole in the cobwebbed attic door to pain. I draw up each transparent syringe of drug and label it, then lay them across my cart like columns of soldiers ready for my commands, and relock the box with a key I wear around my neck.

Mindy, the OR nurse, and Alicia, the scrub tech, arrive and begin setting up their own territories, sorting through stacks of paperwork, unfolding sterile blue drapes across massive tables, adjusting lights, spreading out fields of stainless steel. The three of us have spent countless mornings in chilly operating rooms trading insignificant details of our lives. They have both been at the hospital longer than I have—long enough to know everyone’s first and second spouses as well as a number of surreptitious lovers.

Alicia immigrated from the Philippines and relishes her new American identity. Her eyes are rimmed with black liner that slants to a point. Most women who work in surgery spend the majority of the day with their mouth and nose covered by a mask, their hair encased in paper. Some compensate by drawing all attention to their eyes, like veiled harem dancers. Her hair is an electric orange, and the first time I ran into her without a surgical head covering I didn’t recognize her at all. She’s so tiny she has to stand on a step stool in order to see the surgical field and hand out instruments.

“So are we going to have a good day today, Alicia?”

“Of course, Marrrrrrria!” she trills. “Is there another kind? I’m planning to put the tiniest drizzle of Valium in Stevenson’s morning coffee.”

“Careful—his wife might get used to it and you’ll have to cultivate a steady supply.”

“It’s a good schedule. Too busy to get any add-ons in here. We missed you at the softball game Saturday. The ER staff shut us out.” She places dozens of silver metal clips in perfect parallel rows, their tips marching in a precise line along the edge of the table.

I glance up at her from the head of the bed where I’m arranging EKG leads, splayed like a five-legged spider beneath the pillow. I like to have everything ready, the mechanics of my craft disguised below softer surfaces before my patient lies down and sleep steals in. “You didn’t miss me. When I was in med school I was catcher in a pickup game. They finally made me
the ball back to the mound, my throwing was that bad. Sign me up for soccer.”

“Hey, I got to take my daughter to get braces on her teeth today. You got any drugs for that? For

“Hah! Nothing legal. My sister always gives her kids Tylenol before they get their braces adjusted.” I tuck my bangs back up under my cap and scan my setup one final time. “Did Stevenson ask for anything special on the pediatric case?” Until I meet my patients and read their medical charts, I know almost nothing about them except their names and ages. But Stevenson wouldn’t schedule a child at First Lutheran if she had any major health problems—complicated cases have to be done at Children’s Hospital. Sometimes, though, the room staff can tell me if the surgeon has requested any unusual position or equipment that might affect my anesthetic plan.

“The cyst? Yeah. He wants to do her prone. He was talking about this kid yesterday. I think he said she is a little bit retarded or something.”

I stop working and put my hands on my hips, playing out different approaches to her anesthetic induction, mildly irritated at Stevenson for not telling me about this earlier. With the right preparation I look forward to cases like this—calming a challenging patient in my preoperative interview. I’m playing psychiatrist as well as medicinal artist, a chemical hypnotist beckoning the frightened and the uninitiated into a secure and painless realm of trust. It’s a private world I build with my patient, a world the surgeon never sees, a secret pact that never makes it into the hospital record or onto an insurance billing form. I like to think it is where I can make the most difference—spinning the first layer of the anesthetic cocoon with language instead of drugs.

“OK. I might need a little extra time then, to get some sedation going before we bring her into the room,” I tell Alicia.

“You’re the boss. I go home at three no matter how much time you take.”


My first patient today is a forty-six-year-old woman who will lose her right breast to cancer. I greet her in the surgical holding area, smiling, cheerful, deflecting her anxiety with rapid-fire questions and explanations, reassuring her that she wins the lowest risk classification for undergoing anesthesia—ASA 1 on a scale of 5. She is sitting up in her bed, slender and tanned, wearing light pink lipstick and tasteful eye makeup (for whom, I wonder). It gives the morning a patina of normality, as if she were headed to the tennis club instead of cleaving this invasive parasite from her body.

I feel like I’ve met this woman before, dozens of times. She is the Junior League volunteer, the poised hostess, the sorority alumna usually referenced by her husband’s full name prefixed with a
., polished enough to be mistaken for pampered. She is the woman who does not wince when I start her IV, who asks me about my work and my family and defies me to pity her. She will beat this and move on.

Wrapped warmly on the narrow operating table, I lean next to her ear as she slips beyond knowing, and whisper, “I am right here with you. I will take care of you. You will wake up safe and comfortable. You will recover and be fine.” The faintest rise in her heart rate is the only fear she ever shows.

The case goes well. The steady high pitch of the pulse monitor tells me her red blood cells are richly saturated with oxygen. The slight valleys and peaks of her blood pressure and heart rate guide my mix of anesthetic gas flows, narcotics and fluids. We are in an unspoken physiologic communion, my patient and I. I stand like a sentry at the gate of surgical trespass.

Stevenson is in a good mood this morning, thank God. His kid has just been chosen first-string quarterback in tenth grade, so maybe he is hoping college tuition will be covered. He teases Alicia about setting them up together, the “things” she could teach him. When the patient’s lymph nodes come back from pathology free of cancer the mood lifts for all of us and Stevenson asks for closing music—he likes to suture the skin to Led Zeppelin.

I can almost quantify how well a case is going by the volume of the background music and conversation. People on the outside seem shocked at the irreverence of listening to a hard-rock band while latexed hands split or sew the tissues of living flesh. But I reassure them—that is a good sign. That is the sign your surgeon is walking straight down the center of known territory, so at ease with this procedure his hands are driven by comforting familiarity. That is the sign your anesthesiologist hears the steady high tone of the oxygen and heart monitor and knows, intuits, exactly where in the operation the extra touch of narcotic or the lightened breath of gas will foment the precise balance of chemicals to keep you sleeping, unaware and senseless, until the last bandage is taped, the fresh sheet is pulled over your chest, and you hear the reassuring whisper in your ear, “Wake up, wake up, your surgery is over, and all went well.” We have honed and streamlined surgery until the historical amphitheater with the suited students, the ungloved hands, the chloroformed handkerchief has faded to the initial lurch of an assembly line.

BOOK: Oxygen
3.19Mb size Format: txt, pdf, ePub

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