Oxygen (3 page)

By the time I wheel my patient into the recovery room she is smiling, her cancer drunkenly forgotten in the absolution of drugs. “It looks good,” I say, stroking her hair back from her forehead and handing the chart off to Julia, her recovery nurse. “Dr. Stevenson will be in to talk to you in a few minutes.”

She reaches up to her face; it’s such a common gesture after anesthesia. I’ve come to believe we must need some tactile reconnection with our own lips and eyes and nose to awaken. “It’s over? The surgery’s over?”

“Surgery’s all done, sweetie,” Julia tells her. “Are you having any pain?” My patient shakes her head and relaxes back against her pillows. Julia turns to me. “My niece is coming in next month for a rotator cuff repair with Nuezmann. Would you mind taking care of her?”

“I’d be happy to. Talk to her about an interscalene nerve block. Lots of those patients don’t need pain meds till the next day.”

The recovery room is already filling up, a dozen strangers parked at monitoring stations lined up along the wall like wounded soldiers, a community of catheters and bandages and emesis basins. Even the pretense of privacy is secondary to keeping patients and monitors visible in case an alarm should sound or an airway obstruct. I pull a sheaf of papers from the back of my patient’s chart and start filling out triplicate billing pages and order forms and an anesthetic summary. The top sheet will stay with her permanent record to document my work, while the copies will be parceled out among insurance companies, hospital supply centers, the pharmacy and the anesthesia office, where my professional care will be translated into accounting codes and invoices. One of the nurses has stabbed some freshly cut blue hyacinths into an empty plastic urinal, and I lean over the desk to bury my face in their scent. This may be the closest I get to the outdoors today.

Will Hanover, the senior partner in my group, bumps into me as he rushes from dropping one patient in recovery to meeting the next in the surgical holding area. “Hey!” He steadies me with an arm around my shoulder and slips his surgical mask off his face to dangle below his rotund chin. “Bethany may be adding another case in your room this afternoon. Are you on schedule so far?”

I glance at my watch. “Thirty minutes behind. Can anybody else get Joe out? He was up all night.” First Lutheran hired four new surgeons in the past year, but hasn’t been able to recruit any new anesthesiologists. Will is in charge of our call schedule and spends hours figuring out how to staff all the cases.

“Nobody’s free. This’ll be the third day in a row we haven’t had anyone out of the OR before seven. We should yank Phil out of his meetings and put him back in the operating rooms full-time. Then he’d hire somebody.” Will hikes his scrub pants up higher on his well-padded stomach and tightens the knotted waistband. It seems a gesture he’d like to use on Phil Scoble’s throat right now. Phil is the chief of our anesthesia department and a board member of the hospital. The rest of us have speculated whether this makes him more our advocate or our nemesis, but I think the answer varies in proportion to our fatigue. He has to walk a difficult line, being both one of us and one of “them.”

“Didn’t he make an offer to that woman from New York?”

“He did. So did three other hospitals with better benefits and better pay. I’m gonna give him a Foley catheter for a Christmas present this year—see if he likes the idea of working thirteen hours without a goddamn bathroom break.”

Will splutters in my face as he rants, and I find myself wanting to console him more out of concern for his blood pressure than for collegial bargaining power against the hospital’s rigid budget.

My second case takes longer than expected, and we are an hour-and-a-half behind schedule by the time I greet my third patient. He is a sixty-three-year-old Starbucks executive with newly diagnosed lymphoma, and Stevenson is placing a catheter into the vena cava so he can be treated without the scorching infusion of chemotherapeutic drugs through the smaller veins on his hands and arms. When I meet him in the pre-op area he seems cool and stone-faced, giving me almost curt answers to my questions. I inject a milligram of sedation into his IV and the mask melts into a plea for consolation and hope, a stalling narrative about his newest granddaughter. The extra minutes have got Stevenson pacing in the operating room as he waits for me to bring the patient in. Now Stevenson’s getting testy and he barks at the radiology technician who is helping out, then mutters an apology under his breath, more for himself than the intimidated young woman. His impatience pervades the room, and even Mindy and Alicia stop trying to humor him.

As soon as my patient is asleep I start getting fresh medications and equipment ready for the pediatric case to follow. A child needs more precise drug dosing than an adult; the margin for error is less forgiving, so I dilute the drugs into larger volumes and lower concentrations. Pediatric tubes and scopes and IVs and oxygen masks are all scaled smaller, reminding me of the dollhouses I played with in childhood with their tiny tables and kitchen stoves, their minuscule pans and dishes. The door swings open behind me and Joe walks into the room. He leans across my anesthesia cart on folded arms, his knotted blue veins branching over ruddy freckled hands. I sense Alicia pause in her concentration when she sees him—he has that effect on women.

“Hey. My pancreatectomy got canceled so I’m done. You need a quick break before I go? Coffee in the lounge is only three hours old.” Joe has a way of making everything he says sound mildly humorous. If you don’t know him very well it’s easy to miss his sober side. He has a slight amblyopia, and when he is tired I catch his right eye drifting off center, like he is seeing the world from two points of view. Somehow it only compounds his charm—a detail of vulnerability women love.

“I’m fine. Brad’s supposed to be able to get me a lunch break. You should sleep—seems like you’re always at the hospital these days.”

“My contractor just gave me the bid for my kitchen—I asked Will for extra call. Not like there’s much to race home to.”

“Where’s Claire? Is she complaining about your domestic indifference again?”

“Like all my women.” He winks. “Don’t give me that wily smile.”

“I’m not! I swear.” I clap a hand up over my mask.

“You’re thinking about it, though.”

“You need a dog, Joe. Something loyal and warm to sleep next to you every night.”

This gets him laughing, and under the harsh white operating room lights the wrinkles around his eyes crease all the way to his hairline. Some men really do look better as they age, though I detect Joe’s feeling edgy about growing older. People rib him about being too cavalier, even in the OR, but he’s a dedicated doctor. It’s one of the reasons I like him so much. He put himself through medical school twenty years ago by working in a research lab at night, and he still drives himself relentlessly. He bought an Italian racing bike on a whim, and I teased him about how much it was going to cost him per mile ridden. The next weekend he rode from downtown Seattle up to Paradise Lodge on Mount Rainier and back again.

Stevenson snaps at me to wedge a rolled towel under the patient’s back—he’s having trouble getting the catheter into the vessel—and I have to dive under the surgical drapes to lift the shoulders and head.

Joe hands me a folded towel and whispers, “What’s got him so agitated?”

“We’re running behind. Big surprise. Don’t worry, I’ll get him cheered up. Would you draw up the rest of my drugs for me?” I slip my narcotics key from around my neck and toss it to him. “It’s a child, so I want the fentanyl at five mics per cc.”

“What else?” I hear him peeling open packages of syringes and needles, popping the plastic caps off glass bottles.

“Succinylcholine at two per cc, atropine at one hundred.”

“How much does the child weigh?”

“I don’t know yet. Not an infant—eight, I think?”

I stand up from under the drapes, my hair spilling out from under my cap and my stethoscope dangling by one earpiece from the front of my scrub shirt. Joe is labeling the last syringe, his forehead shines with sweat, and he’s pushed the sleeves of his scrub jacket higher on his forearms. Under his mask is a day’s growth of rough auburn stubble.

“Thanks. Go home,” I say.

He slips my key chain over my neck and tucks my hair back under my cap. “Give me a call this weekend if you want to have dinner. If the weather’s clear we could fly up to Friday Harbor.”

“Hmm. Can’t we do something at sea level?” Joe is a pilot, probably a very competent one—he bought his own plane a year ago. But I have an almost embarrassing fear of heights, and he’s only talked me into flying with him once. My stomach was churning by the time the tires broke loose from the gritty friction of the runway with an alarming, gliding silence. Joe looked at me and reached for an air sickness bag, then burst out laughing when he realized it was only my nerves—his velour seats were safe. Banking over the islands of Puget Sound on a cloudless day, the view would have been glorious, if I could have relaxed enough to keep my eyes open. He kept trying to convince me to take the copilot wheel in my hands, until he finally accepted that my terror wouldn’t budge. “It defies logic. You work in a field that depends on science and mechanics and you have no faith in the principles of lift and thrust,” he chided.

“Oh, I trust the physics,” I shouted over the engine. “What I don’t trust are the humans who build and fly the planes.”

Jolene Jansen
is sitting with her mother in the waiting room, twisting the arm of a frayed pink nylon teddy bear. The portable TV in the corner plays a video of old Looney Tunes cartoons, and Wile E. Coyote springs up after being pushed off a high cliff. When I come in Jolene jumps into her mother’s lap and tucks her face into the open collar of her mother’s shirt. She is small for an eight-year-old. The nurses have not been able to coax Jolene into changing out of her blue jeans, and I can see on her mother’s face this is one battle too many for her this morning. I stuff my mask into my pocket, and pull off my surgical cap so my hair spills out around my shoulders, hoping to look less clinical.

Jolene’s mother looks up at me from the toddler-sized chair she is squatting on. There are no other chairs in the small room; I sit cross-legged beside them on the carpet and try a peek-a-boo game, but Jolene won’t look at me directly. Children often won’t trust me until I’ve won the trust of their parent, so I offer my hand to her mother. “I’m Dr. Heaton. Marie Heaton. I’m Jolene’s anesthesiologist. How are you this morning?”

She shrugs and blows a straggle of brown hair out of her eyes. A flash of nervousness twists her mouth before she answers. “I’m Jolene’s mom. Bobbie Jansen.” She hunches the weight of her daughter higher on her shoulder and drops her voice. “She’s kind of shy, especially around doctors, you know, since she’s been to so many.”

The room is overly warm, and half-moons of sweat bleed under the arms of Bobbie Jansen’s red T-shirt. She smells of woodsmoke and fresh soil and almond-scented lotion. A creased daffodil dangles from a safety pin on her shirt pocket and a matching blossom weaves through the lace eyelets of Jolene’s blouse. I let my hand linger in hers for a moment before I open Jolene’s chart. “Let me look through her records for a minute and we can talk about how I’ll take care of her during her surgery.” I keep my voice light and happy, glancing at Jolene’s buried face now and then to try to catch her eye. Bobbie has a cautious, withholding look, and I wonder if it’s from too little experience with the medical world or too much.

Jolene’s anesthesia sheet is blank, indicating she is healthy enough to have bypassed our pre-op clinic. I turn past the reams of Medicaid forms to Don Stevenson’s surgery clinic note and learn she has only recently moved here from Yakima. Her retardation is fairly mild and not known to be associated with any syndrome that might involve other medical problems. In the past few months she has had recurrent infections in a congenital cyst at the base of her spine, and a walk-in clinic doctor referred her to Stevenson to have it removed. It should be a straightforward, short surgery, the only complicating factor being she will have to be turned facedown on the operating room table after she is asleep. I don’t have any medical documents from her past; no physician seems to have been consistently involved with Jolene, at least inside our hospital system. Her mother will have to tell me what she can.

Bobbie’s eyes move from the open chart to my face and back again as I read, gauging my level of concern for Jolene, my mix of compassion versus science. We are at the balancing moment of trust, and I know my words and gestures will classify me with the caring or the callous doctors she must have dealt with.

I reach up and lightly stroke Jolene’s back, smoothing the ruffle along the hem of her checked blouse. “Has Jolene ever had surgery before, Mrs. Jansen?”

“It’s Ms. Jansen. I’m raising her by myself. No. No, they wanted to put her to sleep once, to do some kind of a test on her, because she was growing so slow, but I wouldn’t let them. I never saw a reason to put her through some doctor’s test that won’t change her future. Only now this infection has made it so she can’t even sit without hurting. That’s why we’ve come.” She scans the room, my nametag, my stethoscope, hesitant, it seems, to look into my face, like she’s looking for something solid to hold on to.

I try to relax my posture, disguise the preanesthetic checklist inside my head. “Did any of her doctors ever say she had a heart murmur? Or any problems with her lungs?”

“She’s healthy so far as I know, except for her mind. But she understands things. She’ll talk to me—just not to strangers. She coughs a lot, sometimes, and she doesn’t like to run around like other kids. But she’s a good, sweet girl, aren’t you, baby?” Bobbie softly rocks side to side, and I see Jolene relax onto her shoulder. Bobbie wipes the corner of Jolene’s mouth with the hem of her T-shirt. Her earlobes and fingers are spare of jewelry; her nails are cut short, clean to the quick.

“When you say she doesn’t run around much, do you mean she can’t?” Bobbie looks quizzical, not understanding the relevance of this question. “I mean, does she seem to get short of breath when she runs, compared to other children?”

“Maybe a little. She’s just always liked to stay quiet. She doesn’t play with a lot of other children…” She trails off.

“But none of her doctors ever told you she had asthma, or any heart problems?”

Bobbie just shakes her head, and the space between us widens. I wait until our eyes connect again. “It’s a difficult job, to raise a child alone.”

“Do you have any kids?”

I clasp my hands around my knees and try to forget that Stevenson is waiting. “No. But I have two nieces and a nephew. My sister’s children. Neil is the same age as Jolene. Do you still have family in Yakima?”

“Not really. Nobody close. Does your sister live here in Seattle?”

“Texas. We grew up there.”

She loosens; a half smile. “I thought I heard some accent.”

I try to weave medical questions, explanations and general conversation into a safety net, asking about allergies and medications and hospitalizations. I put my stethoscope against the pink teddy bear’s back and ask him to take a deep breath, but when I place it over Jolene’s lungs she whimpers and pushes me away. If I force it she’ll wail and I’ll hear nothing anyway. Bobbie tries to persuade Jolene to hold the metal bell herself, but Jolene cries and clings tighter around her neck. Bobbie’s eyes glimmer with tears, and I wonder if I have pushed them both too far. She closes her eyes for a minute, then asks me, “So would you do this? Would you let your nephew have this operation?”

I take her hand again and nod. “I’m going to keep her very safe for you.” She grips my hand like a last chance. Then I coax Bobbie into holding her only child while I inject four milligrams of Midazolam into Jolene’s thigh, pick her up in my arms and carry her down the hallway into the operating room.

By the time we reach room 5 Jolene is drowsily grinning at all the strange masked faces circled above her like witches over a cauldron. The Midazolam has blurred her fear and blunted her memory, so she yields herself up to us. I’m struck by how pretty she is when she is relaxed and smiling. Her skin is perfect, as if it had never seen the sun, cream colored and flushed over the cheek hollows. Her eyes, a lovely, lucid blue, are losing focus and she laughs quietly at some fringe of a dream overtaking her. I wonder if this is the face her mother had before life wore her out.

I bring the clear plastic oxygen mask over her nose and mouth, and her eyes flicker with panic, recognizing strangers, missing her mother. I put my mouth at her left ear and sing softly, a song my mother rocked me to sleep with:

Her hair brushes my cheek. My right hand turns the dial on the gas canister and whiffs of sweet, languid vapors leak from beneath the mask into my own lungs. Jolene’s breaths become quick and shallow, then slower and slower, deeper and deeper, until the regular, even breathing of gas and oxygen in and out tells me she is asleep.

Mindy and I move into action, start her IV, put on her blood pressure and heart monitors, get ready to turn her over. At the deepest moment of sleep I gently extend her neck and insert a metal blade into her mouth. The blade is lighted by a tiny bulb along its shining silver curve so I can see her vocal cords and the dark tunnel of her trachea. I slip a hollow plastic tube between her open cords and attach the other end to corrugated tubing connected to my machine. Now I will breathe for her. I will control the delivery of oxygen to her lungs, her heart, her brain. The nurse telephones the waiting room to let Bobbie know that her daughter is safely asleep.

Stevenson is back in good spirits. He must have had time for lunch between cases, so at least one of us is not starving. That or Alicia threatened to quit if he didn’t stop pouting. He’s telling some far-fetched story about driving his Porsche off the highway into a field of bulls, and his black, bushy eyebrows wiggle above his glasses like a pair of caterpillars. Jolene is floating in a smooth and steady state of anesthesia by now. The chemicals I’ve swirled through her blood and lungs and brain are perfectly balanced against the surgeon’s knife.

Brad Kuciano walks into the room and immediately begins goading Stevenson about some baseball bet he owes him. Stevenson starts the story of the Porsche all over again and Alicia rolls her eyes.

“Hey, Brad. Please tell me you’re here for lunch. I’m starving.”

“Hell no. I just came in to ask Alicia if she’s busy Saturday night.”

Stevenson jumps in: “Too late, Kuciano. I’m setting her up with my son.”

“
I’m
taking Alicia out on Saturday,” I say. “You’re both out of luck.”

Alicia does a quick shimmy on her step stool. “Dancing. She’s taking me to learn the tango, right, Dr. Heaton? We’re
both
wearing high heels and low-cut dresses—getting out of these ugly scrubs.” Her accent rings exotic in the words and I’m almost looking forward to our imagined date.

Brad taps me on the shoulder. “OK. I’ve got three lunch breaks to give in an hour.” He picks up Jolene’s anesthesia page and looks over the dots and dashes that mark blood pressure, heart rate, ventilator settings—sort of a two-dimensional snapshot of her physiology. “A drug rep left pizza in the lounge. Give me a quick rundown and go before the food’s all gone.” He raises his eyebrows. “This patient’s only eight?”

“She’s small for her age, so be careful with your doses. Her face is padded, but I’d check for any pressure points again if the table’s moved.” I fill him in on Jolene’s history and my plan for her anesthetic, point out the drugs I’m giving: fentanyl—a narcotic to blunt her pain, a little Propofol to deepen her sleep, anesthetic gases. It’s almost impossible to talk to Brad without focusing on an enormous Adam’s apple that rides up and down the column of his trachea below his surgical mask. He’s just out of his residency, still swaggering between academic confidence and inexperience, and I catch myself talking to him more like a teacher or mother than a colleague. “Are you comfortable with pediatrics?”

“Sure.” He looks over my setup, checks the row of labeled syringes, gathers in the data he’ll need to take care of Jolene while I eat. “Leave your key in case I need more narcs. And eat a lot—cases are piling up out there, so who knows if you’ll get dinner.”

When I get back from lunch twenty minutes later, I sense more tension in the room. The cyst tracks deeper than Stevenson had expected, and he’s getting short-tempered again. Brad looks relieved to see me.

“She’s been stable,” he says, then leans closer to my ear and whispers, “Wish I could say the same for your surgeon.”

“Sorry. Thanks for lunch. Did you change anything?”

“Gave a little Propofol, a cc of fentanyl, turned your gas up some.” He puts the fentanyl syringe into my hand as he slips out of the room.

Alicia looks up at me and wiggles her eyebrows in imitation of Stevenson. She’s learned to ride the waves of his moods. I look over the surgical drapes and see a much bigger incision than when I left. Jolene’s heart rate increases and her next blood pressure is up, a sign that beneath the sleeping layers of consciousness her body is reacting to pain. I screw the syringe of fentanyl into her IV line and inject more into her. Within minutes her pulse returns to normal and her blood pressure drops.

Someone has changed the background music to classical, Erik Satie’s
Trois Gymnopédies
, an effort to soothe the sleeping giant of Stevenson’s temper, no doubt. He reaches for the scalpel again to open up Jolene’s sacrum. I inject another dose of fentanyl, this time in advance of the electrical jolt of pain that will sear up her spinal cord when he cuts intact skin.

That’s when an alarm sounds. The flashing numbers on the machine behind me show Jolene’s airway pressure rising. It’s probably a kink in the breathing circuit. Or maybe a plug of mucous in her endotracheal tube. The monitors are sensitive and often register some inconsequential change. I reset the alarm but it immediately blares again; the machine strains to push oxygen into her lungs.

I throw a lever and begin to ventilate Jolene by hand using a breathing bag—but there is too much resistance. She might be reacting to the surgery, coughing against the ventilator. Another monitor alarms—her blood pressure has dropped by twenty points and her heart rate is going down.

Mindy looks up and sees the flashing red lights on the screen. “Everything OK, Marie?” She is used to the minor problems that happen during many surgeries and waits to hear the alarm go silent, to know all is under control.

“It will be. Could you mix up some epinephrine for me?”

The reassuringly high pitch of her oxygen monitor is starting to drop, and there is more resistance against the breathing bag. I squeeze it with both hands. I trace the tubing—it’s clear; the blockage must be inside Jolene’s airway passages. I put my stethoscope over her back on the right, on the left, and can hear only faint breath sounds, a high-pitched wheeze when she exhales.

“Mindy, get a suction catheter out of the bottom drawer and hook it up to the vacuum.”

My voice is steady and calm, but I know she hears a new urgency. I slip the catheter down Jolene’s breathing tube to check for plugs. The tube is open.

The numbers on the oxygen monitor begin to spiral down. Any reserve is going fast. Jolene is in bronchospasm. Her smaller airways are swelling and tightening, strangling her from the inside. It must be anaphylaxis—a profound allergic reaction, or undiagnosed asthma. But her heart rate should have increased, at least initially.