Chapter One: Every Patient a Mystery

Every patient is a mystery until the anesthetic begins. Even though there is a pre-anesthetic workup, each patient's reactions vary during exposure to the stresses of anesthesia and surgery. How sound are physiological reflexes, and is s/he less fit or less healthy than seemed pre-op? Why do some steadily deteriorate? There are factors in anesthesia that mandate consideration and yet are unknown to the patient.

What makes some patients worse while under anesthesia? Which are resistant to the several anesthetic agents or muscle relaxants? Anesthetic agents put the patient to sleep, muscle relaxants do not. As derivatives of the curare plant, they merely paralyze. Which patients are sensitive to what will be administered? What are the clues? Does the patient have an unknown or unrecognized disorder? Has the patient taken medicines or perhaps illegal drugs that might complicate anesthesia, particularly amphetamines, cocaine, metabolic stimulants, or other 'uppers' that they were afraid to reveal? Such thoughts continually go through the anesthesiologist's mind, and that keeps the field ever fascinating. There are so many uncertainties during the beginning of an anesthetic that I preferred to anesthetize patients personally, as opposed to helping someone learn anesthesia, for only then could I understand the individual patient's physiologic responses. That feeling likely relates to my initial 5 years in private practice in Denver. Teaching and supervision of others guide them, but the teacher cannot feel the mask on the face, evaluate airway resistance and jaw tightness, measure tongue and throat reflexes, feel how tight or loose the chest is. Furthermore, you gain valuable information from the precordial or esophageal stethoscope, but must routinely listen to it to acquire the skill needed to detect altered sounds that someone might otherwise misinterpret or miss entirely.

Anesthesia is the middle ground between patient and surgeon: About 1990, I was anesthetizing an 11-year-old girl for surgery of her spine. Soon after the operation started, she began to deteriorate as her blood pressure dropped alarmingly, resistant to supportive drugs. Only epinephrine brought her blood pressure to a low normal level. We stopped the procedure, awakened her while resuscitating her, but could not determine what had caused the problem.

I contacted several friends, and one of them, the pediatric anesthesiologist Dr. Marilyn Larach instantly said, "She has a latex allergy."

I'd not heard of that. The girl's allergy was severe, as it caused an anaphylactic reaction, resistant to all but the most potent recuperative drugs. We re-did her a few days later, with non-latex rubber goods, and all went well.

A minor procedure with local anesthesia can become dangerous. A patient may be sedated while her/his condition may be monitored by persons not trained in anesthesia. Sedative drugs are a one way path to general anesthesia, and overdoses can easily occur if the patient is uncomfortable and those providing sedation try too hard to ease tension to facilitate the procedure.

Unfortunately, inexperienced or poorly educated personnel may not recognize early signs of an overdose and continue to push sedation. In fall 2006, a 4-year-old girl died following office dental care in Chicago, the city where I began my medical training. She was given repeated doses of sedatives to quiet her. Afterward, her mother told an aide in the dental office that her daughter wasn't breathing properly. The mother was reassured that all patients breathe that way, but awaken OK. Then the mother noted that the girl had stopped breathing. The dental personnel could not properly treat her, and she died, despite being rushed to a hospital. This is not a mystery. The girl's failure to breathe is easily treated by someone experienced in anesthesia, who would have had the proper equipment and medications set up and ready for just such a mishap.