We are such stuff
As dreams are made on; and our little life
Is rounded with a sleep.
Shakespeare, The Tempest Act IV, sc. 1, 156-158
I remember learning in a Stanford English seminar taught by the amazing poet, N. Scott Momaday, that the word ‘sleep’ in these lines spoken by Prospero in the Tempest is a metaphor for death. It is hard to argue with such literary giants as Momaday or Shakespeare about sleep and dreams, but here we are. I prefer to imagine a “rounded” sleep as a smooth and easy one, devoid of rough awakenings. I wish my dreams were “rounded with a sleep” but mine are jagged ones, more often than not about my work. It is the particularly stressful operating room cases I revisit again and again late into the night, in recursive loops of dread.
To this day, I still dream of a case that happened many years ago. The memory of it startles me awake, troubling my thoughts, causing my heart to race and my breaths to come short and quick, until I calm myself down, sink into my pillow, and will myself back to sleep before morning comes far too early and far too soon.
I am an anesthesiologist in private practice in San Francisco, providing care at several hospitals and surgery centers both large and small. Within the last two years, my primary medical center has built two brand new facilities in the city and retired the old hospitals that have been around for decades. The long-awaited completion of this multi-billion-dollar construction project is the result of the 1989 Loma Prieta earthquake. Following this disaster, the California Assembly passed SB1953, an extension of the Seismic Safety Act first established in 1983, requiring hospitals to complete seismic upgrades, or in the case of my hospitals, retire them and build new ones. It was in one such old hospital, Children’s Hospital on California street, that this story unfolds.
The buzz of activity of a well-run operating room is a sight to behold. Wheeled carts laden with packs of instruments wrapped in sterile blue paper come straight from the autoclave. Machines and monitors, X-Ray C-arms, and operating microscopes are ferried from one room to another. There are even more moving bodies, briskly and purposefully walking the corridors dressed in their blue-green scrubs, and gowns. Surgeons, nurses, and scrub techs work in a coordinated and efficient dance. Patients come and go and are shepherded safely from awake to asleep to awake again in precise fashion by the anesthesiologists at the head of each OR bed. On this particular busy day in the middle of the afternoon, the operating rooms are in full swing, filled with the usual variety of elective cases. In Room One there are urology cases. Rooms Six and Seven are booked with orthopedics. In Room Nine is a long list of breast biopsies. I am in Room Two doing pediatric ENT cases - ear tubes, adenoids and tonsillectomies.
The list of elective surgeries diminishes as one after another is completed and erased from the master OR schedule-board. It is a smooth human assembly line, a model of choreographed efficiency. Patients walk over from pre-op clinic and are ushered into the holding area in their paper, ill-fitting Bair-Hugger gowns waiting to be seen by the circulating nurses and the anesthesiologists. The gowns are ugly, but effective, a distinct improvement over the traditional tied in the back, guaranteed to cause embarrassment, thin cotton gowns. These are disposable, designed to allow hot air from an external blower to circulate throughout built in baffles enveloping the patient in a blanket of warmth to ward off the cold exposure of the operating room.
When cases finish, patients are wheeled out of the OR on gurneys to the recovery room and into the hands of the skilled specialized recovery room nurses. The effects of anesthesia wear off, and any pain or nausea is treated. From there, patients either go home or are admitted to the wards. The latter happens less and less these days. Many operations that once guaranteed a few nights in the hospital are now done on an outpatient basis owing to better surgical techniques and much better anesthetic agents that do not leave a patient feeling hung over for days.
Late in the afternoon the smooth routine of my day is disrupted. A call comes from the emergency room that immediately puts a hold on my next scheduled case. A one-year-old child is being rushed directly from the ambulance bay to the OR for a foreign body airway obstruction. This is unusual, I remember thinking to myself. I would typically go down to the emergency room to evaluate the child, but am told that I don’t have time, as he is in severe distress and already on the elevator. With a sinking feeling I run back to my room to prepare for the case. Beyond what I have already heard, I know nothing else. I don’t know what the child may have aspirated. I don’t know how long he has been in trouble. Even though I have been well trained for this exact situation, my stomach twists, my chest tightens, and I breathe a little faster, fearing this may end badly.
Pediatric airway obstructions are emergencies of the highest order. Ask any anesthesiologist who is also a parent to pick their greatest fear while raising their young children. Mine was choking. Despite an outward appearance of being calm and efficiently competent in emergencies, I can be a fairly anxious individual, especially where my children are concerned.
My family has had to endure countless lectures from me on the “forbidden” foods of childhood - no raw carrots, peanuts, apples, hot dogs, steak, hard candy, etc., until the back molars are established, or the child has graduated from college, whatever comes last. And definitely no talking, laughing, singing, running, or walking around while eating. Once at a birthday party for a friend of my eldest son, Henry, the other parents watched with both shock and embarrassment for me as I put a dramatic, hyperventilating, immediate end to a game of “Chubby Bunny.” If you have never heard or seen of this game, consider yourself lucky. Chubby Bunny is a contest where the children compete to stuff as many marshmallows in their mouth as possible and repeat the words “Chubby Bunny” three times. To me this game is tantamount to attempted child homicide, and a prima facie example of gross parental neglect, justifying a call to Child Protective Services.
After startling all of the kids silent as a result of my sudden and very dramatic outburst, I made them immediately spit out the sticky gobs of marshmallow distending their cheeks like chipmunks. I sarcastically and angrily asked the stunned host mother, “How about a game of William Tell, or knife-throwing next? Do you have any Lawn Darts handy? Or perhaps we can tie up the kids and toss them in the pool to see which one can hold his breath the longest?” Obviously, it took a long time for me to be invited back to birthday parties after that.
From day one of residency, anesthesiologists are taught a simple algorithm: “ABC - Airway, Breathing, Circulation.” In pediatric anesthesiology we are taught an even more succinct algorithm: “AAA - Airway, Airway, Airway.” It doesn’t take long to suffocate when the airway is obstructed. An adult has about three to four minutes after cessation of breathing room air before suffering irreversible brain damage. A toddler may have even less time due to the nature of their more rapid metabolism and high demand of the developing brain for oxygen. This is why the importance of maintaining a patent airway in order to breathe is drilled into us before we even get to touch our first patient.
A great deal of our knowledge and equipment is tailored to achieve this goal. We learn how to assess an airway preoperatively in order to judge the potential risk of losing it once an anesthetic begins, and the patient is rendered unconscious and unable to breathe unaided. We know how to manipulate the jaw in order to tighten the muscles of the neck to support the pharyngeal structures and facilitate breathing. And we know many ways to re-establish an airway once it is lost, including performing an emergency cricothyroidotomy, literally cutting a hole in the neck. Mostly, we know how to do these things in a logical sequence, as rapidly as possible. Time is of the utmost essence.
Treatment of an airway obstructed by a foreign body can range from a simple slap on the back, to a Heimlich maneuver, or even a manual extraction of the offending agent with a finger. This, however, can potentially make things worse by further pushing whatever is causing the blockage deeper into the larynx, cutting off the small amount of air that is getting through. Sometimes anesthesiologists use a special type of curved grasper called a Magill Forceps to pluck an object from the back of the throat after using another instrument called a laryngoscope, a lighted retractor that holds down the tongue allowing us an unobstructed view of the larynx and vocal cords. We use laryngoscopes to “intubate” patients - that is passing a tube through the vocal cords into the trachea in order to establish a secure channel through which we deliver oxygen and anesthetic gases.
As the elevator doors open, I see the huddle of doctors and nurses surrounding the crib of this small child being manually ventilated with oxygen, an ambu-bag mask covering his mouth and nose. I can hear the awful high-pitched squeal and wheeze of the oxygen escaping around the edges of the mask rather than being delivered to the lungs and am afraid that this will not be one of those quick and lucky situations.
The child is decidedly blue, pale around the mouth and eyes. His small fragile body is slack, without muscle tone. We rush into the operating room and place him on the table. The cables are quickly transferred from the transport monitor to my machine, and I take over the task of attempting ventilation. I look up at the monitor that measures the percent oxygen saturation of circulating hemoglobin, the molecule that carries oxygen so efficiently to the rest of the body, to see a number alarmingly in the low twenties. It should be in the high nineties. The lower the number, the lower the pitch the machine makes with each beat of the heart. This pitch portends doom. The heart rate is also steadily decreasing, an ominous sign that this child is about to have a full cardiac arrest.
I inject atropine and then epinephrine into the IV already established by a skilled EMT on the way to the hospital. I quickly look inside his mouth and throat with my laryngoscope and see nothing but mucus and blood - someone has looked before and stirred up a mess. As the pitch of the oximeter drops even lower, I tell the nurse to begin chest compressions and ask the surgeon to prepare to cut the neck to try and establish a surgical airway, a difficult job in an adult, made so much harder in a small child. I force myself to breathe slowly and stop my hands from shaking.
As a desperate last effort, I decide to take one more quick look inside the pharynx with my laryngoscope... and this time I see something different. A small glint, silver and shiny, reflected in the bright fiber-optic light from the tip of my laryngoscope blade. It is the thinnest visible edge of a dime. The rest of it is buried in the swollen tissue, mucus and blood obstructing the vocal cords. It is wedged tightly by its serrated edge. I can understand why the paramedics and the ER doctor missed it. I take the pediatric Magill forceps in my free right hand, fixing my gaze on the tiny crescent moon of the edge of the dime. I don’t want to lose sight of it. Above the background noise, I hear the tone of the pulse oximeter bottoming out, past the point where the numbers are accurate.
The child is purple and mottled. A full arrest is seconds away. I have stopped shaking and my hands are surprisingly steady. I go for the small barely perceptible glint and feel the solid metal between the jaws of the forceps, and I gently and carefully pull it out. A rush of stale air follows. The small coin had acted as a one-way valve, trapping the depleted air behind it and I am now able to freely ventilate the lungs with pure oxygen. After an agonizing number of seconds, I hear the pulse and pitch of the oximeter recover along with the oxygen saturation. The pallid limp child finally and mercifully becomes pink with life-giving fully oxygenated blood and begins to cry.
To this day, even awake, I cannot think about this case without feeling the familiar tightness in my chest, and a stomach-dropping sense of dread. Even though I know this child made a full and symptom free recovery, and even though I have had the opposite experience of having patients die in the operating room who were critically ill, or traumatically injured and not expected to make it, this was the closest I have ever come to losing someone... a child, like this. Working as we do in this environment, at the edge of the precipice, one never knows if the next elevator will be the one that opens to replay the nightmare over again.
My children are grown up now and no longer live with me. But, when they were younger, and still in the safe embrace of my old house in their bedrooms down the hall, I couldn’t help myself. I would awaken, startled from my restless dreams in the deep hours of the night, sit up and listen intently, staring into the dark. I would swing my stiff legs out of bed and walk as quietly as I could down the hall to my daughter’s room. I would stand at her door for a moment, hovering, watching her uncertainly, then softly go to sit on her bed and gently cup my hand near her mouth, reassured. Slowly, deliberately, I would count each warm breath as I stroked her precious face. One...two...three...four...
Jeffrey L. Swisher, M.D