The Doctor and Mr. Dylan (8 page)

One hour past dawn the next day, I was administering my first North Country anesthetic to a 50-year-old man undergoing a shoulder arthroscopy and rotator cuff repair. The surgeon, Dr. Luke Castro, had good hands and a professional demeanor. The surgery was going well, and the anesthetic was routine until I heard the screaming in the hallway outside.

The green-eyed nurse from the day before burst into my operating room and said, “Dr. Castro, we’ve got a major trauma up from the E.R. It was a car versus truck. The driver of the car is all busted up. They’re wheeling him into room #4 now. We need a trauma surgeon stat.”

Castro looked up from the surgery and said, “What are the injuries?”

“He has an open fracture to the femur and a possible tear of the femoral artery. There’s also facial trauma.”

“I’m in the middle of this case right now. Is Dr. Perpich around?”

“They’re calling him, but he hasn’t answered.”

“Do you have an anesthetist to start the case?”

“Dylan is free. He’s in room #4 already. We need a surgeon.”

Castro said, “Damn it, Lena. Give me a minute to clean up the bleeding here, and I’ll come over.”

She left the room, and I had a bad feeling. Yes, they needed a surgeon as soon as possible, but before they could do any surgery there had to be a safe anesthetic. Anesthesia for elective, scheduled surgery is a controlled, predictable exercise. Elective surgery patients have appropriate preoperative assessment, including all necessary diagnostic and therapeutic measures, and their anesthesia can be initiated at a non-hectic pace.

Emergency surgery is another story. The patient often has acute illness and is decompensating in some way that pushes the surgical team to operate without delay. The patient might be bleeding to death, or their stomach might be full of pizza and beer, poised to be regurgitated into the lungs when the patient loses consciousness.

Emergency anesthesia separates experts from pretenders.

Bobby Dylan wasn’t a doctor. He wasn’t an anesthesiologist. How many emergency cases had this Dylan guy done? One hundred? Two hundred? How much could he handle?

My doubts were validated five minutes later. The green-eyed nurse stuck her head into the operating room again and said, “Bobby’s lost the airway. He needs help. Can you come?”

I was in the middle of a stable anesthetic for shoulder surgery. If the patient was dying next door, the choice was a no-brainer. I had to leave. I told the nurse in my operating room to watch my patient’s vital signs monitor, and I ran over to room #4. My heart was pounding. My routine morning had transformed into a battlefield drama.

Welcome to the world of North Country anesthesia.

Inside room #4, Bobby Dylan was hunched over a sphere of red hamburger meat that one hour before had been a man’s head. The hamburger sphere was medium rare, covered in blood, and showed no signs of normal anatomy except for two brown eyes and a wide beak of a nose. Dylan was holding an oxygen mask over the meat. The vital signs monitor confirmed that the patient’s oxygen saturation level was at a dangerous low level of 78%. Any number less than 90% meant the man’s brain and heart were not receiving sufficient oxygen.

Dylan’s eyes were wild and his hands weren’t moving. He looked like a death row criminal stewing over his own mortality. His hands were dormant at a time when he needed to insert a breathing tube and save this man’s life.

“Did you try to intubate him?” I said.

“I can’t get his mouth open. There’s something wrong with his jaw.”

“Did you give him any drugs?”

“I put him asleep with a dose of propofol, but I can’t ventilate him at all.”

“Did you paralyze him?”

“No.”

I put on a pair of gloves and tried to wrench the man’s mouth open. Dylan was right. The jaw was anchored. The teeth were a pearly fence, barring entry. The patient’s oxygen saturation dropped to 70%. At this rate, a cardiac arrest was imminent. “Get Castro in here,” I said. “He needs to trach this guy.” Brain cells died after mere minutes of oxygen deprivation. We needed an emergency airway tube. The man looked like he weighed 300 pounds, and he had a pendulous beard and a stubby neck. I couldn’t feel his trachea below the chin. Cutting into his neck was going to be a serious challenge.

I struggled to fit an oxygen mask over the patient’s face and tried to force oxygen through the mangled anatomy of what used to be a mouth. The patient was gasping for air. Bubbles of dark blood percolated from his nostrils like coffee grounds overrunning a pot.

Castro entered the room. “You need to trach this guy,” I said.

He palpated the patient’s neck and said, “I can’t even feel the trachea under all this fat. This could be a flail. Someone retract his beard to the side. Give me a scalpel.”

He made a slice across the man’s throat. Blood pooled in the wound, and the assisting nurse sponged at the rising red tide. After a full minute, Castro was less than an inch deep into the pulp of the giant neck. The constant bleeding distorted and disguised all normal anatomy, and the windpipe was nowhere in sight.

Castro’s efforts looked futile to me. “Do we have a fiberoptic laryngoscope?” I said.

“I’ll go get it,” a second nurse said.

We couldn’t wait any longer. I selected a breathing tube from the anesthesia equipment cart and said, “Let me try something.”

I inserted the tube into the patient’s right nostril and advanced it through his nose. This maneuver wasn’t without peril. If the man had fractured enough facial bones, the breathing tube could spear right through the nose and enter his brain. I rolled the dice—the threat of cardiac arrest was a powerful motivator.

I lowered my ear toward the man’s face. The rasping sound of his labored breathing crowed through the lumen of the tube. The patient was sucking for his final breaths, like the fish in Dom’s kitchen the night before. Every inhalation was an act of desperation.

At the moment when he sucked in his next breath, I pushed the tube hard into his nose. The patient inhaled the breathing tube into his windpipe, and a lungful of exhaled air shot out through the tube. I connected it to the oxygen circuit and began ventilating the man’s lungs. His chest moved up and down, and the oxygen saturation climbed to 99% in the next minute.

A life saved.

My gamble had worked. It had been as much luck as skill. We’d come so close… too close…to the specter of brain death and cardiac arrest. The patient’s oxygen level had been low for only a few minutes. This guy’s brain would survive. I looked down at his right leg, and diagnosed the next crisis. The man’s femur was deformed into an L-shape, snapped like a twig. Blood was drenching the bed sheets and dripping onto the floor tiles. His thigh was swollen to the size of a small beer keg.

I looked over at Mr. Dylan. His face was washed out and white. He avoided making eye contact with me, and said nothing. Dylan knew how close he’d come to disaster, and how inept he’d been during the crisis. He knew I’d saved his ass.

“You’re going to need to get some blood into this guy fast,” I said. “He’ll bleed his entire blood volume into that thigh before you know it.”

Dylan’s blank, clueless look did not change.

“Do you have some blood coming? From the Blood Bank?”

Green Eyes said, “The E.R. typed and crossed him for four units of blood, but the blood isn’t ready yet.”

“O negative,” I said. “Just get four units of O negative blood in here now. Pump it into this guy before he arrests, or you’ll be doing CPR on an empty heart.”

“Call the Blood Bank,” Dylan blurted out. “Get me four units of O negative.” The nurse anesthetist had snapped out of his stupor, and was showing signs of life and leadership at last.

“Do you guys have a Massive Transfusion Protocol?” I said.

“What’s that?” Dylan said.

“It’s standard stuff at a trauma center. An MTP pack contains four units each of O negative blood, fresh frozen plasma, and platelets. You transfuse the MTP pack in straight away if the patient has massive bleeding. It saves lives. Trauma patients can bleed to death in the first hour.”

Dylan shook his head. “We don’t have anything like that here.”

“You need to have it. I’ll work it out with the Blood Bank for the future. Right now, fire in four units of O negative blood and get the FFP and platelets up here as soon as you can.”

“I will. Thanks,” Dylan said.

“I’ve got a patient asleep across the hall,” I said. “You going to be OK?”

“I’m good. Go.” Dylan clamped five bony fingers across my shoulder and said, “Thanks, Doctor. I owe you.”

“No problem.” I went back to my own operating room. Nothing had changed. My patient was stable. I looked at my written record for the timing of my last documentation. I had been gone for ten minutes.

Ten minutes that felt like an hour.

Castro remained in O.R. #4 to sew the patient’s neck back together after the failed tracheostomy attempt. I had no surgeon, and there was nothing for me to do but monitor my sleeping patient and wait. I sat down and took some deep breaths. I felt conflicting emotions of anxiety and pride. No one could bop in and out of a trauma scene like that without being changed by the adrenaline surge.

It was the sort of episode that defined a man’s life—mine, Dylan’s, and the patient’s—while off the radar screen to the rest of the world. No one outside of the Hibbing General Hospital operating room suite had a clue about what we’d just lived through. The patient was oblivious, as were his relatives. Johnny, sitting in a classroom five blocks away, was oblivious. Alexandra, thousands of miles away, drinking her morning latte and puffing on a Marlboro Light, was just as oblivious. My disconnection from my small family never felt more profound. I was a skilled professional in the hospital, but outside these doors my mooring was tenuous.

The O.R. door opened. The green-eyed nurse entered the operating room and approached me. “That was pretty slick work in there, Doctor,” she said. “I’ve never seen an intubation quite like that.” Her masked face hovered so close I could count the turquoise flecks in her irises. I liked looking at her. She had young eyes, fascinating, intoxicating eyes.

“It was a long shot,” I said. “I’m glad it worked.”

“Where did you learn to do that?”

“I worked in a lot of intensive care units. The blind nasal technique works if a patient is awake and gasping for air. They inhale the tube down into their trachea.”

She cocked her head, wondering that such a fairy tale could be true.

“How’s the patient doing now?” I said.

“Bobby transfused the four units of O negative blood, just like you told him. Dr. Perpich just arrived. There weren’t any pulses in the leg, so Dr. Perpich is doing an angiogram. It looks like he’ll have to repair the femoral artery.”

“What a mess. Why aren’t you in there?”

“The dayshift nurses took over. I just got off night shift. It’s time for me to go home.”

She stood only inches away from me and made no move to leave. She leaned one elbow against my anesthesia machine, and let out a long sigh. The trauma patient episode had been stressful, and Green Eyes had suffered through it like I had. We had that crisis in common, this pixie of a woman and me. She was tiny, no more than five feet tall, with a thin and boyish figure. Her left hand was free of a ring.

I wanted to know her. I offered my hand and said, “I’m Nico Antone.”

“My name is Lena Johnson.” The clasp of her hand was warm, her skin soft. “I heard about you. They say you’re from California.”

“I am.”

“If I had a job in California, I wouldn’t leave it to come to Hibbing, Minnesota.” She pronounced her home state Minnes-oooooh-tah, the word stretched out by an elongated O-sound. She stared back and waited for me to refute the obvious illogic of my translocation. The persistence of her stare made me uncomfortable. At last she asked, “Why did you move up here?”

“I grew up in Hibbing, and moved back so my son could graduate from high school here.”

She lifted one eyebrow. “They don’t have high schools in California?”

“It’s a long story. My son and I decided it would be good for him to transfer to Hibbing High. It’s a great school.”

“I have a daughter in 11th grade.”

“My son’s in 11th grade. You and I can compare notes as the year goes on.”

“Sounds good. Great work today, Dr. Antone. It’s not every day you can save someone’s life.”

“Call me Nico.”

“I’ll call you Dr. Antone, Dr. Antone.” She winked at me and walked away.

Our exchange was like electroshock therapy, bringing a wave of unexpected brightness into a tense morning. I couldn’t remember Alexandra ever acknowledging that I’d saved anyone’s life.

Dr. Castro reentered the room, and donned sterile gown and gloves again. “Everything OK next door?” I said.

“Yep. Perpich arrived. The femoral artery is torn. Once Perpich has repaired that, we’ll deal with the broken leg and the facial trauma. You did a great job in there, Dr. Antone.”

“Thanks.”

Castro chuckled as he resumed the shoulder surgery. “Good God, that was like a fucking TV show episode. Dr. Nico Antone, M.D. In this episode, Dr. Fucking California saves the fucking day.”