The Keepers of the Golden Chalice

When I clicked on the “View Your Exam Results” link on the American Board of Anesthesiology website, I thought something rashly exuberant would engulf me. I thought that everyone in the lunch room would turn suddenly, throw their reheated pasta and cafeteria sandwiches high aloft with glee and balloons would gush from the cracks between the fluorescent lights on the ceiling as the whole world burst into song.

But instead, there was only the word on the computer screen. At the right top corner of the webpage it read “Pass.”

I smiled broadly.

I floated back to the operating room and finished my case. As I saw my friends I told each one, receiving the heartiest hugs that I have ever been given in the hallways of the operating room. It was over.

Board certification in Anesthesiology has four elements. You need to complete an accredited residency program. You need to be neither drug-addicted nor a criminal. You must pass a written examination. And finally, the year after you finish residency and take the written exam, you need to pass an oral board examination. This last step is the most daunting, and I will never have to do it again.

After the new year I decided that I would study for half an hour every day. The exam was in April, so I had four months. Half an hour every day, no excuses. There were some excuses, but they were rare. I started in January, when the sky darkened before I picked the kids up from school and we ate dense, spiced chili with hot cornbread every chance we could get. Every night we would put them to sleep at 7:30 and I would study for half an hour, and many nights the half an hour would bleed on into an hour, and then on into another fifteen minutes, until I went upstairs to sleep.

The key to the oral exam is practicing conveying your ideas out loud. So I would send Miles to the basement, where there is a computer and a TV and a comfortable couch, and I would talk to myself. Read a question, answer it out loud, check the answer. The kids always want to pretend – tigers, Star Wars, mice, dinosaurs, so the pretending was natural. I sat at my kitchen counter for half an hour and pretended that white men in suits were asking me questions and that I was answering each question perfectly. I even laughed. At times I challenged them.

On the day of the exam it was raining in Boston and I parked my car in an expensive garage and borrowed a friend’s suit. It is held twice a year, each time in only one location, and all the oral board examiners and examinees fly there and congregate like flies to fly paper.

Each hotel room has two examiners and one examinee. In each room I worked through a case scenario for 25 minutes and was peppered with unrelated questions for another 10 minutes. The first room contained a nice older white man and a nervous young white man. The second room contained a nice older white man and a nervous young brown woman. They asked reasonable questions. I gave reasonable answers.

After it was over I drove home and ate a peanut butter and jelly sandwich. I drove to my favorite place and went for a six-mile trail run in a light rain. I picked the kids up just as school was getting out. It was a good day.

On my way home after the good news I felt different. My mind wandered to the nights I have been on call, the only anesthesiologist in the cavernous hospital, and the times when I did the right thing. On my first overnight call as an attending my patient, who had had a massive facial trauma, developed a leak in her breathing tube at 2:00 in the morning. “Leave the tube in” the surgeons suggested, “we’ll change it later in the ICU if we need to.” But because the person who would change the endotracheal tube two hours later in the ICU was me, I elected to change it early and prophylactically in the controlled setting of the operating room with the surgeon standing by with a knife in his hand. I told each person exactly what to do and I had three backup plans. It was a scene from one of my nightmares, but I did the right thing. It went smoothly.

The oral boards questions are always imperfect scenarios, where any answer would be at least partially wrong. The reason for failure is often stage fright, but the purpose of the exam is to have a window into how you behave in the operating room. It is the last step toward board certification. The examiners are making sure that you would act reasonably when the answer is not immediately evident. They will pass you if they believe that you will be a good, safe anesthesiologist.

So although I know a few of them and I know that they are fully human, I imagine these oral board examiners as an imposing and heavy-cloaked crew. I see them as my five-year-old would want them to be. It is a dark and stormy night and the Keepers of the Golden Chalice are gathered around the cauldron. They have sipped from its clouded opalescent waters and they have decided who will be invited to dance at midnight under the next full moon, wearing nothing but the white flowers of the night-blooming jasmine in their hair. They have engraved their list on a heavy scroll, and my name is on it.

Witness

The anesthesia scheduling office accidentally placed me in an operating room tomorrow with a patient who is a Jehovah’s Witness. It was a paperwork slip-up; I am new and someone forgot to put my name on the “never” list. There are three options for anesthesiologists at my hospital: You will provide anesthesia for Jehovah’s Witnesses

1. For all operations
2. Only for operations that are not expected to involve great blood loss
3. Never

Of course, all anesthesiologists agree to care for Jehovah’s Witnesses who have a life-threatening emergency if we are the only one available.

I had chosen number three: never. I called the scheduling office and they apologized and switched me to a different operating room.

My lack of faith in any nameable higher being is so firm that I can not reconcile it with what Jehovah’s Witnesses would ask me to do. Their practice comes, of course, from the bible. According to watchtower.org, the official website of the Jehovah’s Witnesses, the belief that “Taking blood into body through mouth or veins violates God's laws” comes from three biblical passages: Gen. 9:3, 4; Lev. 17:14; Acts 15:28, 29. They read as follows, in order as referenced:

“Every moving animal that is alive may serve as food for you. As in the case of green vegetation, I do give it all to you. Only flesh with its soul—its blood—you must not eat.”

“For the soul of every sort of flesh is its blood by the soul in it. Consequently I said to the sons of Israel: You must not eat the blood of any sort of flesh, because the soul of every sort of flesh is its blood. Anyone eating it will be cut off.”

“For the holy spirit and we ourselves have favored adding no further burden to you, except these necessary things, to keep abstaining from things sacrificed to idols and from blood and from things strangled and from fornication. If you carefully keep yourselves from these things, you will prosper. Good health to you!”

A survey of the “beliefs” section of watchtower.org reveals that Jehovah’s Witnesses also believe the following (all verbatim):

            Christ died on a stake, not a cross

            God will eliminate present system of things in the battle at Har-Magedon

            Human death is due to Adam's sin

            Only a little flock of 144,000 go to heaven and rule with Christ

            Satan is invisible ruler of world

Jehovah’s Witnesses’ individual approach to blood products varies somewhat, but the basic premise is simple: they will not receive blood products, even if this refusal will lead to their death. They must sign a special consent form and we go over each blood product individually to determine if they will accept it.

Some refuse blood, plasma and platelets but will accept heat-treated human protein. Some will donate blood for themselves in advance whereas others believe that once it leaves the body it cannot return. Some accept salvaged blood from intraoperative suction devices, and others allow blood to be withdrawn from a vein and re-transfused hours later, as long as the circuit containing the blood was never disconnected from their body.

But for most it is simple. No blood products, even if it means death.

To say that I refuse to care for Jehovah’s Witnesses because I disagree with their beliefs would not quite capture it. We are each entitled to our own beliefs, religious and otherwise. What I am not capable of doing is letting a human being under my medical care die from a completely preventable cause. 

I am morally incapable of letting someone bleed to death. In my operating room, when I am delivering anesthesia, I am responsible completely for that person’s life. This responsibility weighs heavily on me until each patient is safely out of the operating room. I welcome the weight. I care for each person deeply.

I have no religious beliefs. I was raised without religion and am happy for it. I make my own decisions based on the moral and ethical boundaries of my society, self and family. Because I have no religious framework of my own, I am thoroughly incapable of understanding or accepting a Jehovah’s Witness’s stance. To me it seems ridiculous, based on nothing. I will not participate in it. 

We are all entitled to our own beliefs, and I am sure that I will never let a person bleed to death if I can prevent it. So the choice is simple: number three. I do not take care of them. If one comes in bleeding to death in the middle of the night and I am the only anesthesiologist in the hospital, I am stuck. I will do it their way because the alternative is morally inferior. I hope that never happens.

Pause

Mostly it is just terrifying.

I sat on the edge of the bed in my fleece pajamas and tried to describe the fear.

“I’m sure you’ll do great,” my husband tried to reassure me.

“But you don’t understand. Every time you induce general anesthesia, you’re basically almost killing someone. It’s… petrifying.”

“But everyone always said you were a great resident Felicity, you’re going to be a great attending too. I’m sure everything will be fine tomorrow.”

“But that’s the problem. I’m not sure everything will be fine tomorrow. I could easily kill someone tomorrow. Every day I could easily kill someone. I thought I loved this before – as a resident I loved the hard cases, the sick patients, but now it’s… it’s just petrifying.”

I have not killed anyone. I have not come close to killing anyone. I have not had any egregious errors or unexpected complications. I have a strong safety net of other anesthesiologists if I need it. But I am in a continuous state of pure fear.

I thought I loved this, the stress of the unknown, the pure challenge of the most complex physiology. I had no idea how different it would be once the ultimate responsibility rested with me.

There is always the one moment. I connect a patient, a live human whose family I have met and handed a box of tissues to, to the various monitors and give him oxygen to breathe. I cycle the blood pressure cuff and double-check my suction and move all of the airway equipment and all of the drugs into perfect position so that I can reach everything without more than rotating my ankle. I watch the expired oxygen concentration to make sure that the nitrogen in my patient’s lungs has been completely replaced by oxygen. And then, there comes this moment when I turn the stopcock and push the syringe. The medicine is white and it fills the IV tubing completely. When I am done I turn the stopcock again and flush it in completely with saline.

Now it is done. I have taken away the will to breathe. There is no going back now. I must breathe for this patient. It is usually quite easy but if I cannot mask ventilate him and I cannot intubate him then he can die. I have seen that only one time in three years but for now, in these days when I am just beginning that is all I can think of. Every time I turn the stopcock and say “Okay, you’ll feel a little burning in your arm but that’s just the medicine that puts you off to sleep. I’ll take good care of you and you’ll see your family soon,” I am petrified.

So I turn the stopcock. And always for a moment I pause.

Victory Song

Today was a perfect early fall day, the kind when you leave the house in jeans and a fleece jacket and end up sweating through your T-shirt by early afternoon. Keenan raced around the playground after school, red in the face with my handed-down pale freckled complexion. Eli trailed behind him, hiding and seeking the Kindergarten girls along with his big brother.

I struck up a conversation with the mother of Keenan’s playmate. Her daughter was a beautiful, leggy 5-year-old girl with deep dark eyes. In the small talk I mentioned that I am at home this week, but next week Keenan will be back in the before-school program because my husband and I both go to work early.

“What do you do?”

“I’m, well,” I stumbled. “I actually just finished my residency last week, so that’s why I’m on vacation right now, but next week I start work again, so I’m actually… I’m an anesthesiologist.”

Awful. Bad job, Felicity. I need to work on smoothing that out. This will not be the last after-school mom small talk conversation I find myself in when I have to answer that question.

I could stick with the old, “I’m a doctor,” but then people inevitably ask what kind of doctor and so really this only mystifies the profession more severely and makes it sound as if you were trying to make it sound intimidating, when it already sounds intimidating.

Anesthesiologist. Ten times fast. “What do I do? Well, I’m an, I’m an, I’m an anesthesiologist.”

I finished residency last week, at 4:29 PM on a Wednesday. I just walked out of the operating room, changed out of my scrubs, picked the kids up from school and made dinner.

Although publicly awkward, I want to sing a victory song. After eight years of medical training I am done. It started in Baltimore, on a steaming day in late summer. None of us realized that the T-shirts we wore that first day would be emblazoned on an I.D. badge attached to our little white coats for four years.

I got hit by a car on my road bike in the fall of my third year of medical school, and I spent two months after that cordoned on the couch, left leg tightly braced, knitting baby sweaters and imagining having a baby to put them on (and reading medical physiology of course). Keenan was born a year to the day after the accident. Eli was born nearly three years later. I worked a full day, had dinner on the back deck, and went back to the hospital to have a baby before bedtime. When my in-laws brought Keenan to the hospital to visit the next morning he hit the big red emergency button on the wall – because it was red, and large. He saw Eli’s umbilical cord and was impressed that his baby brother had, in his estimation, two penises. The baby sweaters are in a storage box in the basement now, waiting for someone to have a baby so I can pass them along. Eli is two years old. Sometimes now they giggle with an evil sound and run away, together, laughing.

The victory song goes like this. I am thirty-three years old. I am an anesthesiologist. If the unthinkable happens and you come to my operating room I will do everything perfectly. I will double-check the drugs before I give them to you. I will track your blood pressure closely and slow your speeding heart down. I will treat your pain skillfully. When you awaken I will look into your eyes and I will calm you. I have wanted this for so long, and I have two beautiful children and a husband who have endured every single one of the two hundred nights I have slept in the hospital over the last four years, and I am going to make it all worth it. I am going to do a perfect job.

Encephalopathy

He taunted me encephalopathically from his hospital bed. He called me closer.

“Can I get some of those drugs now?”

“No, I can’t give you the sedation until we are in the endoscopy room,” I answered.

“Oh.” His bearded face and yellow eyes were briefly sad, until the memory of our conversation faded into the hepatitic haze.

“Hey, can I get some of those drugs now?”

“Nope, I’m not giving you any drugs until I hook you up to the monitors, and that doesn’t happen until I take you into the endoscopy room.” I tired of my own answers, rearranging words to appease my own desire for a freshly structured sentence. He did not tire.

“So, are you going to start the drugs now?” He asked, again for the first time.

I tried to cancel it, the whole thing, but his daughters did not realize that he was dying. They knew that he kept bleeding and that the bleeding was the start of the whole thing and that the doctors might be able to stop the bleeding, so they agreed to the endoscopy. It is hard to tell what dying looks like if you have never seen it so close before.

He never stopped drinking, but he starting vomiting up blood one day and went to the emergency room. He was almost dead then but they saved him, pumping him full of cold red blood cells, plasma and platelets as his body ejected it, again and again. His liver was ruined, he was bleeding to death and he was still drunk. The doctors put a breathing tube in and did an endoscopy, sliding a long thick tube into his esophagus and tying off the bleeders with thin rubber bands.

It worked. The bleeding stopped. He withdrew from the alcohol violently and slowly. The breathing tube came out. But his kidneys stopped working completely and the doctors put a dialysis catheter into a thick vein in his neck so a machine could do the work meant for kidneys. His blood stopped clotting and the transfusions poured in. His liver no longer did anything really, just took up space in the hardened right upper quadrant of his distended abdomen. It didn’t make the clotting factors that prevent blood from pouring out endlessly from every scratch. It didn’t filter out the toxins that were poisoning his brain. It was thick and hard and wouldn’t let blood pass through, so the blood backed up into the blue distended veins that lined his esophagus, and every so often they would burst, and the blood would pour out.

I had never seen numbers this bad.

“Damn!” I muttered to myself as I looked over his chart in the morning.

“Damn.”

“He is sick.”

I armored myself against the Gastroenterologist who would be doing the procedure. I calculated his MELD score, the number for grading the severity of liver dysfunction that assigns a slot on the liver transplant list.

My patient would not be getting a liver transplant. You have to convincingly and permanently stop drinking before anyone will give you a new liver, but the MELD score is based on several predictive laboratory values and can be plugged into a number of other scientifically verified calculators for estimating outcomes. I thought the result would help convince everyone to steer entirely clear of this man.

His 90-day mortality was 97%. So it was nearly sure that he would be dead in three months.

His 7-day postoperative mortality was 71%, meaning that if I gave him anesthesia for a procedure, there was a 71% chance that he would be dead in a week. His 30-day postoperative mortality was 98%: he was virtually guaranteed to be dead in a month if we did something to him.

The bottom line was that he was dying, and doing a procedure, despite its benefits, brought with it added risks. He would die soon with or without it. It could slow down the bleeding, but it would require an anesthetic that could easily tip him over the edge and it was impossible to know which force would prevail. I did not want an anesthetic provided by me to be the most proximate cause of his inevitable death.

My heavily armored argument failed. The Gastroenterologist understood me but was defenseless against the patient’s daughters, who wanted “everything done.”

I retreated back to the procedure room and talked with the endoscopy nurse as we set up for another case.

“It’s funny, it’s accepted that you can say no to some cases, but there’s really only two reasons. If he was a Jehovah’s witness I could refuse to do the anesthesia for the case and nobody would bat an eyelash. If it was an abortion I could refuse to participate. But him, he’s just dying and I think we should just leave him alone, and everyone looks at me cross-eyed when I say we should cancel it. I wouldn’t even think of refusing to personally do the case.”

But another bad thing happened in the hospital then and I was swept away to where I was needed and never saw him again. If this were a book I would have the right ending, I would know how and when he died and I would teach a lesson to you. I would paint you a picture of the thick droplets of blood slowly passing inward as the thin yellowed blood oozed out. I would tell you what the faces of his daughters looked like when they said to me, “We just didn’t expect it this soon. We didn’t think he was dying.” But this is a blog, so the story does not end, but continues on as we continue on, imperfectly.

CPR

When I stepped out of the revolving door in the hospital lobby this morning the air was cool and moist. There were pockmarks on the sidewalk from where raindrops had been and a man and a woman were smoking. They sat on the curb and through the open back of his hospital gown a tatoo snaked down his left side. Her hospital I.D. bracelet hung from the narrow part of her left arm and she smoked with her right. I walked slowly.

The air was only cool in the way that the morning is cool. It was opressively wet but it had not yet started to warm. I walked slowly and undeliberately toward the bicycle rack on the ground floor of the parking garage. Twenty-four hours had passed since I locked my bike to the rack and walked into this building. There had been a lot of sick patients and I was tired. It was time for me to go home.

A policeman directed traffic agressively through the intersection caddycorner to the hospital’s main entrance. I waited until he signaled me to cross. A cluster of ambulances was blocking the road adjacent to the sidewalk that leads to the parking garage.

Another policeman signaled me to walk alongside the ambulances in the road, not on the sidewalk. As I rounded the corner I saw the flash of a steel laryngoscope blade entering a fat man’s mouth. The man was having a cardiac arrest on the sidewalk and he was being intubated by an EMT. His body recoiled with each chest compression. The man with the laryngoscope blade got the breathing tube in on the first try. I walked slowly. I was wearing a T-shirt and gym shorts and sandals and carried my bike helmet in my left hand. I hoped that they could get the fat man up off the sidewalk. There is some sort of construction and there are barricades along the sidewalk, but there were about twenty of them and they looked strong.

Pleurodesis

I tortured a man who will die soon.

In the afternoon, when I found out what cases I was assigned for the next day, I trudged up to the Intensive Care Unit to grudgingly filter through two weeks’ of notes from doctors and nurses of all kinds who had relentlessly tried, without any success, to help George get better.

His lungs were bad. He was in the final stages of emphysema, a disease in which the connecting, elastic fibers of the lungs rot out and dissolve, leaving behind a floppy, over-explanded lung incapable of relaxing inward after each breath.

His journey through my hospital had started two weeks before, when his left lung had collapsed yet again and he was wheeled into the emergency room hoping that somebody could help him. It was very hard to breathe.

Over years the elastic connective tissue in both of his lungs was horribly stretched, but in the top corner of his left lung, they had stretched and stretched until a bleb had formed, an air-filled pocket whose contents were completely excluded from the rest of the lung. The bleb no longer participated in the taking in of oxygen and releasing of carbon dioxide that a lung is meant to do.

One Monday morning, the bleb popped. George breathed air in, and instead of air flowing into the alveoli, the microscopic gas-exchange units that line the lung, the air he breathed in traveled through his mouth, past his vocal cords into the trachea, down into the bronchi and out through the popped bleb, and curled back around the outside of his lung, compressing the very thing from which it arose.

This is called a pneumothorax. The latin is simple: air chest. The mechanics are simple. The lung cannot expand. Your own breaths fight you.

When he rolled into the Emergency Room, gaspingly short of breath, George wanted the lung fixed. The surgeons told him that the lung could be reexpanded with an operation, so on that afternoon they entered his chest. They used a caustic solution to irritate the lining of the lung, hoping the inflammation they caused would be enough to get the lining of the lung to once again adhere to the inner lining of the chest wall. This is called pleurodesis. The pleura is the lining of the lung, and –desis means “to stop.”

The chest x-ray after the surgery was unchanged: there it was, the left lung, collapsed into the bottom inner corner of its half of the chest, compressed by the product of its own breaths, too weak and floppy to expand back into place, to move air in and out again.

After the first few sleepless nights in the Intensive Care Unit, the fluid started to build up. His kidneys had been going downhill for years, and they just couldn’t keep up anymore. The doctors kept giving him IV fluid because he was wasn’t eating and his blood pressure was low, but his kidneys couldn’t keep up and clear the water he didn’t need.

As his kidneys struggled to keep up with the fluid it began to seep across membranes, to weep across the cell-thick tissues that separate the body’s essential liquids into different compartments. There was too much water, and it pushed and drizzled its way through to infiltrate the far corners of his body, until the fluid under his skin made a soft weeping imprint where his arm rested against the edge of his glasses as he fell asleep.

The fluid oozed out of his lungs too, into the space around his lungs, and on the left side it fought for space with the air from the pneumothorax, leaving little room for the lung itself.

He needed oxygen. At first, when he came into the emergency room, he just needed four liters per minute through his nose, a little more than he used at home, just enough to bump his oxygen level up to normal.

When I met him, fifty-five liters per minute of oxygen were flowing through his nose, and an oxygen mask was blowing more in through his mouth. He sat forward in bed, gasping and grunting with each breath.

He was tired. He was thin, and old, and he wasn’t making any sense. I was tired too, so I filled out the paperwork and rushed out of the Intensive Care Unit, eager to get home.

The next day in the late morning an ICU nurse and two orderlies pushed George’s bed into the elevator and brought him down to the operating room. Outside the double doors to the operating room I took the anesthesia resident’s customary spot at the head of the bed, watching the blood pressure, heart rate and oxygen level on the transport monitor while pushing the weight of the hospital bed with both arms. George was grunting.

The surgeons had this idea, to bring this sick old man to the operating room, because they wanted to make things better for him. Every day they had to snake a bronchoscope through his mouth and into his lungs to suction out the thick secretions that lay there, clogging up the small airways whose patency were vital to his survival. He was too weak to cough the secretions up anymore. So every day a thoracic surgeon slid a long thin fiberoptic bronchoscope, a narrow tube with suction capability and a camera on the end, through George’s mouth and deep into his lungs and found the plugs of mucus waiting there and sucked it all out. It was horrible. Every day they did it, and it was hard to give him any sedation because he could barely breathe to begin with, and the whole thing made him cough so much.

George also couldn’t eat anymore. He just didn’t have the strength, and he was working so hard to breathe, so it was no longer safe for him to feed himself. He had a thin yellow tube snaking down to his stomach from his right nostril, but that could clog up after days.

He was coming to the operating room for a mini-tracheostomy, a hole in his neck that would let the surgeons suction out his lungs easily whenever the need arose, and for a feeding tube placed directly into his stomach through a small hole in the skin overlying it, so he could get nutrition reliably and safely.

The alternative, of course, was dying.

But he was old and sick and tired and he was working so hard to breathe that he couldn’t really speak much, so his wife signed the forms and I pushed his stretcher, heavy and slow, back to the operating room that I had painstakingly prepared for him.

The feeding tube was first. I poured liquid lidocaine into an oxygen mask and turned up the flow. The lidocaine became aerosolized, floating in and out of his gaping mouth with every breath. The back of his throat became numb enough for the surgeon to insert the endoscope, about an inch across and feet long, into his mouth, past his esophagus and into his stomach. George fought it at first, then settled into it, the surgeon sliding the scope in and out to visualize the folds of the stomach, the surgery fellow pinching the skin of his abdomen with more numbing medicine, then the pressure as the fellow eased a thin tube through the surface of his body and into his stomach.

We could have put him to sleep. We could have flushed medications into the small IV in the third finger of his right hand that would have removed all conciousness, blunted all pain, and relaxed his muscles. We could have then inserted a thin plastic breathing tube into his mouth and attached that tube to a ventilator. We could have asked the surgeons to make a bigger hole in his neck, one that we could attach to a ventilator to breathe for him. And at the end, when the holes had been made in his stomach and his neck, we would have taken the breathing tube out of his mouth and connected the ventilator to the tracheostomy and transported him back upstairs to the ICU. Just one single dose of anesthetic would have been enough to guarantee that he stay dependent on the ventilator for the rest of his life. Once the weak muscles of his diaphragm felt that extra push of air coming from the breathing machine they would have lost their own drive. So when we planned out this anesthetic, when we found out we were taking a sick dying man to the operating room that was fighting for every breath, my attending and I decided to keep him awake. Their were two options: keep him completely awake for the procedure, or guarantee he need a ventilator forever. Rarely is something in medicine so sure.

George struggled through the feeding tube placement, but once the wide tube of the endoscope was out of his mouth he relaxed a bit, renewing his attention to breathing and bringing his oxygen level back almost to normal.

Next came the tracheostomy. This time the surgeon slid a bronchoscope in through the back of George’s numb mouth and now, instead of sliding down the esophagus, he angled the camera upward, tucking under the epiglottis we all watched on the video screen and diving between the vocal cords and into the trachea, the conduit to the lungs. With every breath the rings of cartilage lining his trachea bounced up and down, pulled by the weak muscles of his neck and chest. The surgeon struggled to keep the camera in the right place.

George winced as the surgery fellow numbed his neck with lidocaine. George was struggling. I was holding his forehead back with my left  hand, proferring his outstretched neck to the surgeons.

“I can’t see you. Are you through the skin even?” The surgical fellow was struggling to pass the tracheostomy tube through the skin as the surgeon watched from the inside with the bronchoscope.

“I can’t advance it. I can’t even see where I am on the video screen. Are you still in the trachea? He’s moving too much.”

The surgeon pulled the bronchoscope completely out and changed spots with his fellow. The fellow passed the bronchoscope again and again I held George’s oxygen mask tightly on. George was sitting bolt upright, still struggling to breathe. Again he surgeons could see nothing, again the movement was too much. There was blood in the airway now too: they had entered the trachea once, twice, but never could they see well enough with the bronchoscope to guide them all the way in safely.

I took out an LMA and smothered it with thick lidocaine ointment. George’s oxygen level was dipping now. The LMA, or Laryngeal Mask Airway, is a piece of soft inflatable plastic, oval in shape, that is attached to a stiff plastic tube. You insert it in the mouth and pass it past the back of the tongue and it seats just above the entrance to the lungs. It seals off the back of the throat and you can push air into the lungs without having to insert a breathing tube all the way in, farther down.

This LMA was big though, as long as George’s outstretched hand, and I put it in his mouth with him wide awake, wide-eyed and staring at me.

“George I’m going to put this little breathing thing in the back of your throat because your oxygen level is getting really low. It’s going to help me breathe for you. I know it’s uncomfortable, but you should still be numb back there.”

The LMA twisted in the back of his throat and he struggled. I pulled it out. Again I put it in and this time it dropped into place. The surgeon slid the bronchoscope through it and slid in and out of the trachea, again and again, suctioning out blood and trying in vain to see well enough to place the tracheostomy tube that was the reason why we were all here all together in this operating room. I held the LMA tightly in my left hand, pulling with my wrist on George’s forehead, keeping his neck cocked back as the surgeon tried again and again to make the perfect hole in his neck.

“We can’t get it. I’m pulling out.”

And it ended. I stopped squeezing the ventilation bag with my right hand, I looked in George’s eyes and I pulled the LMA out. He coughed up thick piles of blood. His oxygen level dropped and rebounded, again and again. He was no different from when I met him the afternoon before, sitting upright and gasping at breaths, grunting unmelodically in between. He had a feeding tube now, and a couple of needle holes in his neck, but he was alive and still pulling each thin breath in on his own.

We moved him back to the hospital bed that he arrived on and brought him up the slow elevator to the ICU. A team of nurses and doctors greeted us.

“They couldn’t get the trach. Feeding tube went in fine. Local only, no sedation.”

Outside George’s room, I filled the ICU doctor in on the details of the procedure, me clenching the LMA tightly in my left hand while my wild-eyed patient struggled to breathe while the bronchoscope passed into his trachea again and again.

 _____________________________________________________

A week later I passed the ICU doctor in the hallway. He was tall with short-cropped blonde hair and piercing green eyes.

“Remember that guy you dropped off on Monday afternoon?”

“I wish I could forget it.”

“On Tuesday he cleared. All of a sudden everything lifted and he wasn’t confused anymore. He said he was done with everything and he wanted to go home to die. We called psychiatry to come because nobody believed him, but they said he was totally lucid. It took his wife a while to get used to the idea because she had been signing all the consents up until then, but she came around. He went home on Hospice on Thursday.”

“That’s the best outcome he could hope for. We tortured him. If only he’d cleared a week earlier.”

If only he knew exactly what it meant when he came into the hospital three weeks before that, when he said he wanted everything done.