Losing them, fixing them, forgetting to put them in
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At the age of five I was a sickly kid, with monthly throat infections that spread to my eardrums, making my ears hurt as if some angry god were throwing darts at them. My parents brought me to specialists, who recommended a tonsillectomy. It was the prevailing wisdom in the 1950s. Today the tonsils are widely believed to perform an immune function, but at that time no one thought tonsils did anything other than become infected.
My parents gave me a book called Peter Ponsil Lost His Tonsil. The book had bright pictures showing what tonsils looked like. It showed Peter in the hospital with smiling nurses and doctors. It showed him at home after the operation, laughing with his parents and eating ice cream and opening presents. But it glossed over the actual trip to the operating room.
We drove to the hospital the afternoon before my surgery. My parents waited with me for a time, then kissed me goodbye, handed me over to a genial nurse, and left. The book had prepared me for this, though I can’t imagine the separation was easy for me, or for my parents. But that’s how hospitals did it in the fifties. I spent the night in a wheeled metal bed in a big room with several other children, all sleeping in similar beds and all having their tonsils taken out the next day.
In the morning the nurses came to get us one by one. A bed with a child doing his best to be brave would be rolled out, and when it returned, the child would be asleep.
“See,” the nurse would say, “here’s Tommy, back from his surgery.”
Finally it was my turn. A man guided my bed through the halls into a drab, echoing room. No one spoke to me. I was lifted onto a narrow gurney, and a pair of hands placed a sort of cup upside down over my face. A sickly sweet smell was filling the cup. The book hadn’t mentioned this.
“Please take that off me,” I said politely.
Good manners having had no effect, I reached to bat the cup off my face. Suddenly huge, sinewy bands pinned my arms, legs, and head. The cup, or whatever it was, remained over my face. I screamed and kicked, but it didn’t do any good. The room whirled until my screams seemed very far away, and a syrupy thickness descended.
I woke back in my hospital room. I don’t remember the sore throat. I don’t remember my parents’ coming the next morning, nor the ice cream and presents in the days that followed. What I do remember is that force pinning me down and how no one in that operating room said a word to me.
I’m now an anesthesiologist, and I can say with certainty that my experience was typical. I know this because I always inquire about a patient’s prior surgeries, and if they’re about my age and have had a childhood tonsillectomy, I ask if they recall the anesthetic. Most remember it just the way I do.
The cup placed over my face was actually a small wire colander with surgical gauze draped on top. Ether was then dripped onto the gauze. Nowadays inhaled anesthetics are contained in vaporizers and added to the mixture of gases delivered through the anesthesia mask, but this older technique, called “open-drop ether,” had been used continuously for more than a hundred years before my operation.
When I began my residency in the 1970s, ether was on the way out, not because it’s a bad anesthetic — it’s a very good one — but because ether is flammable, and once in every three hundred thousand cases or so, despite precautions, a fire or explosion would occur in an operating room. And there is nothing like a patient’s catching fire to get a doctor’s attention.
About the time of my tonsillectomy, a British chemist named Charles Suckling succeeded in attaching some atoms of chlorine, fluorine, and bromine to the ether molecule, displacing the flammable hydrogen atoms. The result, christened “halothane,” wouldn’t ignite. Halothane eventually replaced ether as the inhaled anesthetic of choice in the United States. Unfortunately it had the disadvantage of causing severe hepatitis in one out of every thirty thousand patients. Half those cases were fatal. This made halothane more dangerous than ether, whose fires, though dramatic, were ten times less frequent and only occasionally lethal. What medical body, you might well ask, deemed ten cases of hepatitis more acceptable than one fire? The answer is: no medical body at all. The switch to halothane was brought about by private insurance companies’ refusal to write liability policies for operating rooms using ether.
Other halogenated ethers have since been synthesized. None of them cause hepatitis, but neither are they perfect. The search for the ideal anesthetic gas goes on.
One summer, a decade after my tonsillectomy, I attended a camp on a private bay. A wooden raft anchored offshore had a makeshift diving apparatus on it: a glass-and-metal helmet attached by a hose to a manual air pump. A boy could plunge off the raft with the helmet over his head to explore the fish and plant life twenty feet down while a buddy worked the pump to supply fresh air.
I remember the water was a gorgeous shade of turquoise, and the aqueous ferns waved seductively below the surface. I couldn’t wait to go diving, but when it was my turn, I panicked as the helmet came down over my head. I’d had no idea it would be so heavy. (The thought that it would become lighter in the water didn’t occur to me.) Feeling trapped, I reached to push the helmet off my shoulders, but it seemed to weigh a hundred pounds.
“Please, take it off me!” I shrieked.
The counselor complied, and I gulped the fresh air and lay on the deck shaking, unable to talk.
“Want to try again?” the counselor asked after I’d recovered.
I did not want to try again. No amount of cajoling could induce me to put that helmet on another time. If you’ve ever had a panic reaction, you know: its authority is absolute. There’s no choice involved, no reasoning. There isn’t even a “you.” You are gone; the panic is running the show.
A dozen years later, during my medical internship, I came to the hospital early for rounds. I made my way through a side entrance to an infrequently used elevator, because the elevators by the main entrance were always crowded and slow. The elevator came right away, and I got in and pushed the button for my floor. The doors closed, but the elevator didn’t move. I pressed the button again. Still no movement. I pressed the OPEN DOOR button. Nothing. I began hitting all the buttons, my anxiety growing with each try. I was in a dead elevator. This had never happened to me before. As far as I was concerned, I was trapped in my own coffin. My mouth went dry, and my heart raced. I knew in a few more seconds I would lose control and start screaming. Just then the doors opened, and I bolted out and collapsed on a nearby bench, gasping as if I had been underwater. From then on I used the elevators at the main entrance.
It was several years before I connected the two panic episodes to my experience on the operating table during my tonsillectomy. Maybe the fear I’d felt when I was pinned down and given ether caused the later reactions; maybe not. All I can say is that I’ve developed a healthy respect for small, enclosed spaces. I make sure my cellphone is charged when I get on an elevator, and I avoid any that are off the beaten track. I like talking to elevator repairmen whenever I get the chance.
I wish I could say that recognizing my fears automatically made me a more empathetic physician, but it didn’t. It made me more capable of empathy, but I still had to build connections with patients the hard way, as a patient I’ll call “Gail” taught me.
Gail was thirty-one and about to have her arm reconstructed. Her husband had beaten her often during their short marriage. She’d escaped to a shelter, taken out a restraining order, and moved to a new apartment, but he’d discovered her new address and dropped in one night to beg for another chance. When she refused, he shot her in the arm, causing extensive nerve damage. He was now serving time for attempted murder.
Gail was terrified of going under. She’d already had one life-threatening experience, and, from her point of view, here was another. “You’ve been doing this a long time, haven’t you?” she asked me.
“Of course, of course,” I said.
What she needed was for me to listen to her fears in the most genuine way I could, but in the process of taking her history, I’d become preoccupied with my anger toward her husband: what kind of man could do a thing like this?
“When is your husband getting out of jail?” I asked.
“In two years.”
“I know what I’d do before he gets out,” I said. “I’d get a gun and learn how to use it.”
Gail didn’t answer. Her face clouded over, and she retreated inward, away from my anger. Any chance I’d had to ease her fears was gone. When I gave her the anesthetic, I murmured my usual words of comfort: “You’re going to get sleepy now. I’ll be here all the time watching over you.” But Gail was no longer listening. She was facing her terror alone.
Since then I’ve learned to listen to patients talk about what scares them. Most of them fear giving up control, and so long as it doesn’t interfere with operating-room safety, I defer to them as much as possible. If someone tells me he’s afraid of the anesthesia mask, I don’t use it while he’s awake. If a patient wants to go to sleep slowly because she’s terrified of a sudden loss of consciousness, then that’s the way we do it. If another wants to go to sleep fast because a leisurely approach to oblivion is what frightens him, I put him to sleep quickly. Intravenous agents, which can cause rapid loss of consciousness, have become the standard. The only catch is you need an IV line in place to use them. This is not usually a problem for adults, but most young children have a terror of needles, so inhaled anesthetics are still the norm for them.
I have sympathy for the anesthesiologist who gave me open-drop ether, because he had a tough job. He wasn’t very good at it, and if I ever meet him again I’d like to reward his bedside manner with a few choice words. But I concede he had a challenge. Moreover, children don’t leave much room for error: the smaller they are, the greater the risk of an overdose. I’ve met anesthesiologists who claim to be comfortable anesthetizing children, but I don’t believe them.
I met Alex in the pre-op holding room. She was two and had the same problem I once had: repeated ear infections. She needed a myringotomy: a small incision in the eardrum to drain fluid from the middle ear. A beautiful child with big pale green eyes that gave her a startled look, she clung to her parents.
I introduced myself and took a small teddy bear out of my pocket.
“This is Mr. Bear,” I said. “He lives here at the hospital, so he can’t go home with you, but he’s having an operation today and needs someone to look after him. I think he might be a little scared.”
If a child is old enough to look at me, I believe, she’s old enough to understand. If nothing else, this approach usually reassures the parents, which is half the battle. Children will react as their parents do: A mother who can barely hold herself together creates the impression in her young daughter that the world is ending. Calm parents tell the daughter that she’ll live to see another day. Alex’s parents were holding up well, and Alex immediately took to the bear.
I brought out an anesthesia mask. “Mr. Bear is also having an ear operation,” I said. “He can go to sleep either with a shot or by breathing into the mask. What do you think you’d choose?”
“Shot” is what I call the IV. I always pitch the idea because it means I don’t have to bother with the mask, and should trouble arise, it gives me a way to quickly administer drugs. Even patients who choose inhaled anesthesia will get an IV after they are under. But kids Alex’s age seldom choose a needle, and Alex was no exception. I let her try putting the mask on the bear, and while she was occupied, I chatted with her parents about her medical history, described what would happen, and answered their questions. I like to enlist the mother’s and father’s help whenever possible. When I started practicing, parents weren’t permitted in my hospital’s OR, and I proposed allowing them in with their children. The rule change took many months to be adopted.
Alex’s mother, Kathy, came into the OR with her, and while Alex was lying on the operating table, I explained about each of the monitors: EKG, blood-pressure cuff, pulse oximeter, stethoscope. Alex particularly liked the pulse oximeter, a clothespinlike device clipped to her thumb that transmitted her blood-oxygen concentration to the room’s computer screens.
I propped the bear up on her chest where she could see him. Kathy held her daughter’s hand, and I took the bear’s anesthesia mask and connected it to my machine, then showed Alex the anesthesia bag. “If you hold the mask on your face just right, you can make the bag move in and out.”
Alex tried this with 100 percent oxygen flowing through but decided she didn’t like it. I set the mask sideways on her chin and switched to 100 percent nitrous oxide (aka laughing gas). As it began to take effect, I maneuvered the mask loosely over her nose and mouth. This time she let me do it. You can’t safely give 100 percent nitrous oxide for long, so I added oxygen to the mix and another anesthetic agent, as laughing gas isn’t potent enough on its own. By then I was holding the mask on Alex’s face tight enough to form a seal. Within a few seconds her eyes closed.
The operation went smoothly. Alex woke in recovery with both parents at her side. Her ears didn’t even hurt.
I once read an account of a man trapped for nearly two days in a Manhattan elevator. Footage from the elevator’s security camera is posted on the Internet, and you can see time-lapse video of his entire ordeal. I find it agonizing to watch, but I have done so several times, because it’s good preparation for listening to patients’ fears. It quiets me and helps me feel more tender. When they tell me what they’re afraid of, I try not to solve or dispel their concerns. I don’t assure them they are safe in my hands or that there is nothing to worry about. I shut my mouth and think of elevators.
Wolf Pascoe’s Essay “Going Under” [January 2011] reminds me of the time I was admitted to Children’s Memorial Hospital in Chicago more than fifty years ago. My appendix had ruptured, and I needed emergency surgery. A hospital staff member took the time to talk with me, a seven-year-old, and calmly explain that I needed surgery. This took away some of my fear. I decided years ago to leave Children’s Memorial something in my will — all because someone decided, as Wolf Pascoe did, that it was important to talk to a child.