Chapter Twelve: Mayo Clinic -- Neuroanesthesia

Chapter 12 Sub-sections

Mayo is unique: isolated, organized better than most, productive, adaptable, and supportive. It is a small city in southeastern Minnesota, 75 miles south of Minneapolis/St. Paul, and about 350 miles northwest of Chicago. It is a company town, originally only with Mayo, and later, an added IBM development plant. We initially lived in Rochester, but later moved to a small farm, near the village of Pine Island.

Mayo Clinic has large outpatient, administrative, and research buildings in addition to its two hospitals. Its anesthesia group included staff physicians, nurse anesthetists, residents, and nurse anesthetist students. At that time, there were 75 operating rooms in the two hospitals: Methodist, across the street from the downtown clinic buildings, and St. Mary's, a mile west on Second Street. Each specialty area, consisting of anywhere from four to 15 operating rooms, had its own anesthesia physicians, supervisory nurse anesthetists, staff nurse anesthetists, and rotating residents and student anesthetists. With this arrangement, there was virtually no poor anesthesia care, because several persons checked on each case. Most areas had good care, and some superb care. The system's main strength was in its long term people. These upper mid-westerners were serious and conscientious about the quality of their work. They virtually never missed work, no matter how severe the Minnesota weather.

In Rochester, an individual's balance and ego support were sometimes tenuous because of the number of capable people. There was the feeling that this was a large pond in a small place, with only a few big fish. Mayo took very good care of its physicians (described by some in maternal terms). It provided a decent salary and comprehensive family health care. It did your income taxes, granted generous vacation and professional absences, and supported your practice with capable aides, technicians, and nurses.

Mayo did well for medicine, and capable people were enticed to work there. The organization of record keeping and its efficiency was and is phenomenal. The Mayo ego manifested itself in those who took it seriously, and that, at times, offended others. But that could be neutralized. On one occasion, I rented a car at O'Hare airport in Chicago.

The clerk asked me where I was employed; I replied, ‘Mayo Clinic."

He said, "Is that spelled m-a-l-e?"

That broke me up and reminds me of Bill Clinton's experience at a home for old people with Alzheimer's. He was walking along a corridor, caught up with an older man, walked with him, held his hand, and asked, "Do you know who I am?"

The man replied, "No, but ask the woman at the desk, she'll tell you."

Neuroanesthesia

Neuroanesthesia, with colleagues Jack Michenfelder and Kai Rehder, involved four neurosurgical operating rooms until 1981, when a new wing expanded it to six rooms and two induction rooms (each placed between a pair of operating rooms). Annual case numbers included about 500 craniotomies; there were an additional 250 sitting-position procedures (posterior fossa exploration, cervical spine procedures), craniotomies for vascular cases and tumors; 150 trans-sphenoidal hypophysectomies; 150 carotid endarterectomies by the vascular neurosurgeons (vascular surgeons had their own carotids), and lumbar laminectomies.

Each surgeon operated every other day, and saw patients in clinic on alternate days. Internists, neurologists, and pediatricians evaluated patients in addition to surgeons. If they had a surgical problem, they were placed on the next day's schedule, no matter how full it was. There could be long days in the operating rooms.

It was only a few years before I began my neuroanesthesia career that neuroanesthesia was updated at Mayo, when they switched from ether to halothane. Many patients were operated on in the prone or face down position, particularly for operations opening the back of the head or neck. An experienced and capable senior nurse anesthetist I worked with, Bernadine McGovern, who celebrated her 90th birthday a few years ago, vividly described that experience. Supervised by an anesthesiologist, she sat on a small stool under the head of the operating table, poured ether into a cloth, and held it up to the face of the intubated patient to maintain anesthesia. She stayed that way for several hours at a time, with periodic relief. As she put it, she was determined to make this anesthetic the best possible. This approach would be unbelievable in this day and age. She was breathing fumes almost as much as the patient was! Wonderful stamina, but she was steady and reliable and a wonder to work with. One particular aggressive neurosurgeon insisted on use of ether, because it was the only agent and technique that he'd seen. He finally changed when he saw that patients given the new agent halothane didn't lie in the recovery room retching and vomiting. This was so routine with ether that he believed that this was part and parcel of all anesthesia.

Dave Dahlin, the Mayo pathologist with expertise in bone diseases, and I became handball partners and good friends. He added much to my adaptation to Mayo life, as he was practical, unaffected although famous for his contributions to diseases of bone, and didn't suffer fools. He was a South Dakota farm boy who decided to go to medical school. As he put it, when plowing a field, he sat on the plow behind the harnessed mare. Going into the wind on a hot summer day, when she had to pee, the warm shower all over him was easily the best promoter of a field other than farming. He and I graduated from the same medical school, although he preceded me by 20 years.

Thor Sundt, My Second Hero in Life

Thor Sundt was a parallel in character and personality to Art Prevedel. They were selfless and always providing for others, hard workers, and as surgically skilled as any I have seen. I've already described Art's performance under unexpected pressure. Thor was a vascular neurosurgeon who behaved similarly when confronted with unexpected major challenges. He performed carotid endarterectomies, and became Mayo's leading surgeon for ruptured aneurysms. He earned grant support for laboratory research and had collaborative projects with Jack Michenfelder, due to their combined interests in the metabolism and circulation of the brain. He was well respected and had his ego well under control, despite his fame in neurosurgical practice and research. He supported his staff and was beloved by his patients.

Lois and Thor Sundt had a bull mastiff, Winston, who resembled the historical Winston Churchill. One day he bit down so hard on a bone that he locked his jaws on it. I came over to their home, and injected thiopental, intravenously. He slept easily. Thiopental doesn't relax muscles very well, even though the patient is deeply asleep, and we had to pry Winston's jaws open with a crowbar to remove the bone.

Thor developed multiple myeloma in the 1980s and continued to work throughout. CBS' 60 Minutes devoted a program to him, helping to document his contributions and his continued clinical and research productivity despite his disease. He died in 1992. Art had died in 1989, several years after developing metastatic colon carcinoma, and the loss of them both was indeed great.

Impressive Talent in Anesthesia at Mayo

When I became faculty at Mayo in August 1966, several other anesthesia people entered the picture. Roy Cucchiara (later chair of the anesthesia departments at Mayo and then the University of Florida, Gainesville) came from New Orleans as a six week medical student preceptor in anesthesia, and I was his mentor. Joe Messick (a solid contributor for Mayo's anesthesia department and its teaching) came from a Navy residency, and Sheila Muldoon (later chair of the department at the Uniformed Services School of the Health Sciences, Bethesda) came from anesthesia training in Ireland, both for anesthesia fellowships. The smooth and diplomatic Alan Sessler was beginning the respiratory care service with the superbly capable nurse anesthetist Bernie Gilles.

Dick Theye was the chief of anesthesia research, with Kai Rehder and Jack Michenfelder starting their own programs at Mayo. Kai, a former Mayo research fellow, had just returned from Germany to stay in the U.S. He had fought in World War II as an artillery gunner helping to protect Hamburg, and was in terrifying situations for a teenager. When he emigrated from Germany and was questioned about military service, he said that he'd served, and nothing more was asked, even though he'd fought for the opposing side!

German academic anesthesia practice had frustrated him. As he described it, the surgeon was the dictator: at the end of a case, he not only decided whether the anesthesiologist could bill the patient, he determined the amount.

Theye was discerning, tough, clever, and coldly objective. He could be supportive or unfairly damning. He respected those who would stand up to him and his abuse. He was a member of the American Board of Anesthesiology and an emotionally mutilating examiner to candidates taking the oral examination for certification. John Kampine (former Chair, Department of Anesthesiology, Medical College of Wisconsin, Milwaukee) was a junior examiner with Theye, and said that his behavior could at times be awful. Cucchiara took his boards in Minneapolis and was waiting in the hotel corridor with other candidates outside their respective examining rooms. Roy knew Theye well, since he had performed research in his laboratory. (The board examination comes in for greater detail later on.)

The door of the room next to his opened and Theye's voice boomed out, "OK, come in here – let's see what you can do to kill your patient!"

His candidate's nervousness prior to entering the room was nothing in comparison to how much worse it was after this diatribe. Joe Garfield, an anesthesiologist colleague of mine at the burn unit in San Antonio, had Theye as an examiner in spring, 1969. Joe, who passed, described Theye as a first rate agent for the FBI. His questions were deliberate, defined, pointed, and without a single unnecessary word. Theye was tough but not unfair to him.

Theye told me a story of Nick Greene and the first edition of his landmark monograph on spinal anesthesia (Greene, 1958). The late Dr. Greene, later my good friend and an overall excellent influence, was a well regarded academic anesthesiologist. He had trained at Harvard, been chair at Yale, and edited two major anesthesia journals – Anesthesiology and Anesthesia Analgesia. But his first edition on spinal anesthesia had a major error in physiology, because he had mis-interpreted what took place after a spinal anesthetic took effect.

Theye corrected Greene's error in physiology. Greene had stated that the sympathetic block and vasodilation of spinal anesthesia would lead to a greater volume of blood in contact with cells, and a greater uptake of oxygen (Greene, pp 52, 54). However he failed to assess this in terms of reality: tissue oxygen consumption increases only with increased muscle tone or activity, increased temperature, or in the situation of prior inadequate blood flow, as is sometimes seen in septic shock (Bihari et al, 1987). Oxygen consumption of a tissue (or the leg) is the product of blood flow and the difference between arterial oxygen content and that of venous outflow. Greene saw increased blood flow in the leg, but that only implied greater oxygen availability to the tissue, not increased consumption. In actuality, venous oxygen levels increased, because extraction was unchanged, while flow had increased.

Greene appeared to be confused with the increased whole body extraction of oxygen and the resulting diminished mixed venous oxygen content, due to the well documented diminution in cardiac output during spinal anesthesia (Greene, pp 52, 67). In the leg, since overall tissue oxygen consumption is unchanged, there is less oxygen extraction from the blood, and femoral venous oxygen content increases (p 54). At that time, there was little data reporting increased femoral venous oxygen levels, and Greene had questioned the results of the single study reporting it. He corrected his error in later editions.

Theye discussed the great variations in academic mortality uncovered by the National Halothane Study (National Halothane Study, 1969). The study estimated unexplained mortality after halothane anesthesia, since there was an onus on halothane as a hepatic toxin. There were fewer than ten unexplained deaths following its use among some 900,000 anesthetics in 35 hospitals, documenting the safety of halothane (see prior discussion of our early US Army Burn Unit publication).

Surprisingly though, there was a ten fold difference in mortality among academic centers in healthy patients undergoing surgery that was unlikely to have significant mortality. This dramatic disparity has never been explained, and, as Theye stated, no one has investigated it.

Academics Can Be Nasty

Theye wasn't the only academic who showed nastiness. At a meeting in the 1970s of the Association of Academic Anesthesiologists (AUA) --- the honor society of academic anesthesiology --- some expressed concern regarding the increased numbers of foreign medical school graduates entering anesthesia. A clever, articulate, humorous U.S. academic chair, an immigrant himself from an English-speaking country, rose to speak at a floor microphone. He said that this influx was an embarrassment, and described these immigrants in colorful, insensitive, racially-insulting terms. My recollection is that some thought these comments were hilarious in context, but others properly and strongly criticized the speaker.

Theye as Mentor

Theye was a potent and capable investigator and administrator. He was my mentor in research and provided sound support and advice. He knew what to avoid and how to gain the most benefit in planning a series of studies. He realized the dictum, that mentoring has to be performed consistently over a sustained period of time and preferably one on one. I appreciated his example when I began to mentor others.

Mayo encouraged research and directly supported it. For each dollar of an individual's NIH funding, Mayo provided matching funds, a generous practice virtually unheard of in other academic institutions. Mayo recognized the value of research in maintaining reputation and standing. In my research, I had the additional funds and 50% non-clinical time. Theye loosened his oversight as I progressed. After his death in 1977, I became principal investigator of our NIH grant, and renewed the five year grant in 1979. After 1984, my numerous grant proposals were not funded. An NIH grant is invaluable in support of research, as it provides money from the federal government rather than drain the lesser reserves of a university or clinic. It automatically provides non-clinical time for research, which many institutions don't provide unless you have outside funding. However mentoring was not easily productive.

At the University of California at Davis, I mentored five potential researchers in anesthesia. To begin studies, and to maintain the effort, requires a certain fire and drive, and perhaps a more effective mentor. Several of my young researchers were but briefly effective. Joe Antognini persisted and succeeded. He was a bright and inquisitive senior resident when I arrived at Davis, and, after finishing, was in private practice for four years before returning to academia. He had always wanted to study mechanisms of anesthesia and had determination. He initiated his research while still in private practice, and found it fascinating.

Joe needed minimal mentoring, but he needed it immediately when he did need it, and I was always available. Once started, he simply soared into productivity and earned NIH grants. I did direct him to his goat model of cerebral vascular isolation for study of spinal cord vs. brain mechanisms of anesthesia; once involved with that, his mentoring needs were minimal.

Eulogy – Best to Just Sit Down

Theye died of the bulbar form of amyotrophic lateral sclerosis in fall 1977. He was Jack Michenfelder's mentor and close friend. At the next AUA meeting after Theye's death, the president asked Jack to provide a eulogy. Jack agreed, since he knew that if he refused, the president would ask someone else. At the meeting, Jack stood up and said, "For those of you who knew Dick, the most appropriate thing I can do is sit down," which he did. Jack unfortunately died in May 2004 of a self-inflicted cranial gunshot wound.

Dick, Jack, and Kai furiously guarded their research commitment and non-clinical time, and could be nasty about it. They were all more or less fascinating, but at times inconsiderate and harsh to others. Their defects reflected their ambition and intense drive. Kai had the Teutonic-directed superior ego. Jack was quite an actor and assumed roles depending upon need and goals. He could be friendly or otherwise, and acted within the rules, but barely. He was more talented than most at discerning the essence of a problem. He had a great sense of humor, and was clever, but on occasion characterized hard working people with such cutting sarcasm and biting humor that it became awkward and uncomfortable.

Others laughed, but the victims, even years later, never forgot. Jack spared no one and challenged anyone. He didn't follow diplomacy, or any rules except his own, and those were sometimes difficult to identify. There were three women on the anesthesia faculty, and he characterized the most successful and conscientious as the ‘best of a bad lot.' Her hard feelings were not expressed to him until years later, during a private discussion. She described it to me, and said that even afterward it was a bitter memory.

At this time, the old theory that surgeons were captain of the ship was being balanced by the role of the anesthesiologist. As Jack put it, when one neurosurgeon claimed that we worked for him: "We don't work for the surgeon; we work with the surgeon for the patient." When that wasn't strong enough, he said that if the surgeons ran the ship, then they had to go to court in our place for any lawsuits. That ended arguments between them and us. Besides, they soon realized that we offered far more than they could in patient management during a difficult procedure. The solution to this problem had started for me in private practice.

In general, surgeon-anesthesia relationships were easy and respectful at Mayo. One contribution to overall neuro specialty rapport was the monthly good-natured poker games organized by Jack. It included anesthesiologists - Jack, Brian Dawson, me – and neurosurgeons - Ed Laws, Sundt, Burt Onofrio, and George Baker – sometimes a pathologist, sometimes a radiologist. These games rotated among the various homes, with food and liquid refreshments provided by the host. They started about 8 p.m. and ended promptly at midnight. They were frequently hilarious and effective in easing working relationships. About $25-30 per person, at most, changed hands.

In fall 1966, Kai, Jack, and I began writing a review on neuroanesthesia, perhaps the first comprehensive one on that topic, published in Anesthesiology (Michenfelder et al, 1969). I prepared and wrote 1/3 of the manuscript with guidance from Jack and Kai, an in depth learning experience. The title's brevity (Neuroanesthesia) was unfortunately ignored when the neuroanesthesia subspecialty group began its own journal several years later, with its wordy title.

About this time, our chair Albert Faulconer and I discussed my possibilities for non-clinical research time supported by Mayo until I earned an outside grant. I cited Theye's change from private practice to research and wished to do the same. Faulconer was not particularly encouraging or supportive. He reminded me that Theye had been first in his class in medical school at the University of Indiana, and that I had not, at the University of Illinois. I didn't argue about my relative merits, nor my concomitant jobs, but waited until later. At that time at Mayo, I was trying to advance my academic standing.