Chapter Seven: My Early Anesthesia

Chapter 7 Sub-sections

After medical school and internship, I began my residency in July 1959 at the University of Colorado in Denver. I had chosen this locale because I yearned to live near mountains. I had loved a vacation in Estes Park at age 17, and I'd married the Montana native Pat Sparlin. My residency included Colorado General Hospital, Denver General Hospital -- the city hospital for poor and trauma, National Jewish Hospital for lung and heart specialties, and Los Angeles Children's Hospital, for a valuable four month pediatric experience.

The University of Colorado department chair, Robert W. Virtue, Ph.D., M.D., was awkward with his hands, but he was intellectually stimulating and particularly admired scholarship. For example, he soon noted that I was co-author on two papers with Dr. Schwartz in the American Journal of Physiology and had me autograph copies. When John Severinghaus presented a departmental talk on morphine, Dr. Virtue told us of his exceptional abilities and promise. Dr. Virtue on another occasion told us to look into the medical library to see a young anesthesiologist spending the week there to prepare for his anesthesia oral board exams, with books and papers scattered all over the library table. This was Ted Eger, visiting his sister. Ted became an icon in anesthesia, for his research and his penetrating inexhaustible mind. He was also a Chicago product, and had attended Hyde Park High School, near the University of Chicago.

It is impossible to adequately explain the importance and significance of the contributions of Severinghaus and Eger to the development of modern anesthesia. They had phenomenal success in research and teaching and were pillars of strength in the academic world. Severinghaus was both an outstanding anesthesiologist and applied physiologist and a developer of the blood gas techniques used to track progress in ill patients. As residents, we knew just enough to be in awe with our exposure to them.

New Resident Training

There were two new residents each summer, at this time, Keith Preston and I. We new residents were tutored by all, but a resident a year ahead of me took me over from day one. Lou Lopez, five years older, showed me the ropes, what not to do, and how to learn through the system. He became my ‘father figure' throughout my professional life. He had this easy relaxed approach to life and appreciated whatever came his way, but this came due to hard work.

Lou was born January 20, 1928 in Maxwell, New Mexico, population 400. When he was 7-years-old, his mother died, and his father, a mail carrier, placed his sister and him in a boarding school in Raton, New Mexico. His brother, Paul, was placed in the school for the blind in Alamogordo, New Mexico.

Lou served in the US Army from 1945 to 1948, and then attended Colorado College, the prominent school in Colorado Springs. He did this on the GI bill, the first in his family to earn a degree. He worked as a gardener in Englewood, Colorado to pay his way through medical school at the University of Colorado. He followed this with his residency, and a practice of anesthesia in Denver for more than 35 years. He helped and encouraged me throughout our lives, no matter where I lived or what I was doing.

As to beginning residency, he advised me to rely on the departmental nurse anesthetist, Casey, or Julia Kassanchuk, for the best clinical teaching. He warned me, "If you treat her as an underling, she will ignore you for your entire residency." She knew all the clinical tricks. For example, early in my residency, when we did a thoracic case, we intubated the trachea in the lateral position -- as she put it, if the tube comes out during the case, you'll have to replace it in that position anyway, so why not get some practice? It also confirmed what she said, "It's easy to intubate in that position; it's an almost straight line passage directly into the trachea."

This helped me greatly, later, in re-intubating patients in the prone position. None of my own patients were extubated prone (unless deliberately), but I did successfully re-intubate some five or six prone patients over the decades for other anesthesia people. These were ongoing operations with the patient face down for access to the site of surgery. When the tube in the patient's trachea becomes dislodged in the prone position, this is a terrifying situation: ventilation may be difficult to impossible, there may be loss of oxygen to her/him with total loss of ventilation, and turning the patient is a hazard because of the open surgical wound. Worse yet, there is decidedly no time to wait to solve this. The solution is a unique mystery in each particular patient, and a frightening challenge. It is valuable to re-intubate the trachea without turning the patient to the face up position. The approach is to lift one shoulder and turn the head a bit towards you. Intubation is then generally feasible, even though you sort of stand on your head to get a decent view into the back of the throat.

First Night Emergency Call

When I began night call, my tutor was the late Harvey Brown, an older (36) senior resident, who was to teach me judgment and proper decisions. He was unbothered by custom or tradition, had a great sense of humor, and couldn't be cajoled or threatened.

While on call, we slept in the daytime recovery room, which was used as a night-time recovery area for postoperative cardiac patients. If problems developed, it was easier to go to the operating room just down the hall, instead of crowding onto an elevator from the surgical intensive care unit up to the operating rooms. When stable, the patients were taken from the recovery room to the ICU. No emergencies were scheduled until after the cardiac patient was stable and in the ICU. After that, emergency cases could be scheduled. The temporarily closed operating room suite was not a serious problem because serious cases involving trauma or other problems generally went to Denver General Hospital or one of Denver's private hospitals.

One night, about 2 a.m., just after the cardiac case had been moved out, the chief surgical resident came loudly into the recovery room -- typical of the surgical ego then, he roared into the room, turned on the lights, and said, "Let there be light" -- and told us equally loudly that he had an appendectomy to perform. Harvey listened to the description of the modest findings in this patient, and told the resident that there was an unscheduled operating room at 7 a.m., and that the appendectomy could be done then. The surgical resident protested vehemently, eventually saying that the patient might die if not operated upon very soon.

Harvey responded, "Well, we won't do this one, but, if he dies, we'll do the next one." The patient was operated on in the morning and did just fine. A hilarious teaching experience.

Painful Learning Cases

In September 1959, now three months as a resident, I was gaining confidence but lost some of that with a case that so impressed a third year medical student that he too became an anesthesiologist. He and I were in the cystoscopy room on the first floor, below and isolated from the second floor main operating rooms at the old Colorado General Hospital. Once the case was started, our faculty went back upstairs, and was available if called. A 4-5 year old boy was undergoing circumcision, and a urology resident was the surgeon. We were using open drop ether on a gauze cone, and during the procedure, I was explaining that the pattern of breathing was typical of light anesthesia, and that we needed to deepen it. But I had misinterpreted the respiratory pattern, which actually was diaphragmatic tugging, indicating deep anesthesia. So we dripped more ether, and the patient stopped breathing. Without respiration, the next stage would be cardiac arrest, at that time treated by incising the chest with a scalpel and performing open cardiac massage.

I said, "He's stopped breathing," and the student repeated, "He's stopped breathing."

The surgeon, understandably worried, said, "Is this a cardiac arrest?" He was worried that he might have to cut open the chest wall to manually massage the heart.

We all stared dumbfounded at this immobile child, and then he started breathing again -- while we were frozen in place, the ether was being re-distributed by the circulation from the brain and the respiratory center to other areas of the body. Once the ether levels in the brain decreased, the respiratory depression dissipated, and breathing re-started. I had known of this mechanism, but had not seen it before, and had not immediately thought of it when respiratory arrest occurred. I was now much more cognizant of the signs in anesthesia. Our patient had not actually been in trouble, as his apnea lasted about 20-30 seconds. In part, luck had prevented a catastrophe, and my medical student was dumbfounded at his new insight into physiological changes during anesthesia. Actually, so was I. But soon there was another lesson.

Laryngospasm is a potentially catastrophic complication of anesthesia. The patient cannot move air, nor can manual compression of the reservoir bag force oxygen into the lungs. It can be difficult to treat, and is easiest to break with the muscle relaxant succinylcholine. At Denver General Hospital, I anesthetized a 16-month-old infant for an eye examination. I was about nine months into my residency training and had not had much experience with small children. My faculty helped with induction and intubation, and then went to a lecture in our anesthesia conference room, about 150 feet down the hall. We were using cyclopropane, notorious for sensitizing the airway for laryngospasm.

After the eye examination, I waited until the baby seemed awake and reactive enough, and removed the endotracheal tube. I heard a slight high-pitched ‘bleep' on the precordial stethoscope, and knew that laryngospasm had started. I could not break it with positive pressure. We did not have an intravenous, so I could not inject a relaxant to relax the vocal cords. The scene had been surreal. The ophthalmologists were talking quietly on the side of the operating room, the nurses were cleaning up, and none had any idea that there was a problem. They couldn't have helped anyway, and might have panicked.

Without saying anything, I was desperately trying to get oxygen into the baby's lungs with positive pressure by face mask. We had no quick method to get immediate help, as all anesthesia personnel were at the conference, and there was no direct alarm system. I could hear his heart rate slowing more and more. I continued in attempts to force oxygen past his tightly closed vocal cords and into his lungs. Perhaps a few small amounts got in, and helped. The laryngospasm finally broke at the time the heart rate reached about 40 beats per minute.

That reminded me of an old saying: "Laryngospasm breaks just before the heart stops" (including mine!). He survived uneventfully.

Clinical Research, Not to Boast of

The University of Colorado performed research in those earlier days when ethics were not yet clearly defined, i.e., specific directives limiting research on patients had not yet been applied. Our chair Dr. Virtue and a pulmonary physiologist-physician were conducting a research study at National Jewish Hospital to evaluate shunt factor during thoracotomy. Certain conditions exaggerate shunt, particularly operations with the chest open and compression of one of the lungs. Shunt is the deficiency of oxygen in arterial blood compared to the maximum possible at a given alveolar oxygen partial pressure.

For the study, Dr. Virtue specifically directed me to give a 30-year-old man an anesthetic consisting entirely of large doses of morphine and a tranquilizer plus a skeletal muscle relaxant so the patient would inspire only oxygen, thus ensuring accuracy for shunt measurements. This anesthetic is generally insufficient for adequate anesthesia without nitrous oxide, but they believed that greater morphine doses and the added tranquilizer would be satisfactory. No permission was requested from the patient, nor was he told that research would be performed on him during his lung surgery.

As soon as he was extubated at the end of the procedure, the patient complained bitterly about awareness -- he picturesquely described the knife cutting across his chest while muscle paralysis prevented voluntary movement. We tried to convince him that he had dreamed this, or that he was feeling chest pain during application of the chest dressing, but we couldn't make him think otherwise, and he was correct. Not a good moment. I had trusted my chief and his colleague and I now regretted it.

LA Children's Hospital

My pediatric anesthesia rotation at Los Angeles Children's Hospital involved four months with the formidable chief M. Digby Leigh. Pat was due to deliver our daughter Nancy while we were in LA, and we never considered that this might be an inconvenience, so we traveled, leaving Denver in August, 1960, during the second year of residency. Pat had no problems traveling. Sixteen month old Brian was a trooper and went along with whatever we arranged. We camped at national parks, sleeping in the back of our station wagon, and Pat cooked on the tailgate with a Coleman stove.

On the way, we decided to visit the Grand Canyon. The south rim was out of our way, so we chose the north rim, drove southeast to Colorado City and then about 60 miles on an unpaved road ("impassable when wet") to Toroweap Overlook. In our naïveté, we had not considered how isolated this could be. We saw no one, not even at a ranger station some 5 miles prior to the overlook, and found that the overlook had no railings, let alone facilities. We set things up for supper and sleeping, and I took photos of an uncomfortable Pat holding 16-month-old Brian, sitting near the edge. Fig. 6a, b. Again, we didn't worry about being isolated while Pat was pregnant. As she put it, Montanans were virtually always isolated.

Figure 6a
Fig. 6a. Colorado River from Toroweap Overlook

After a bit, the ranger drove up, customarily friendly. He greeted us by our license plate, "Hi, Colorado," and said that no one comes to his area, and that even he doesn't try to drive that awful road. He routinely flew a small plane for shopping and local travel. Pat, Brian and I had a good meal and a quiet starlit night. In the morning we re-traced our steps (fortunately no rain).

Figure 6b
Fig. 6b. Pat and Brian at Toroweap Overlook

In LA, as we were in the ‘destitute' category of patients, Pat was delivered by the OB resident on the charity service of Hollywood Presbyterian Hospital. Nancy was born November 3, 1960, several weeks after Clark Gable had died there.

LA Children's was an active anesthesia group in a very large city, with the best and most challenging cases. The Canadian M. Digby Leigh was chair. Teaching and the variety of cases were excellent, with a push to all of us residents to assume the efficiency of private practice (this was seldom possible in academic teaching programs). One of the best locales was the heart/lung operating room for heart cases on cardiopulmonary bypass and various pulmonary procedures for congenital and acquired disorders. The second, and most useful for us going into more ordinary anesthesia practice, was the ENT room. We were taught to excel at anesthesia for tonsillectomy and adenoidectomy. In the past, most had used open drop and insufflated ether, without an endotracheal tube, and with a considerable risk of aspiration. Other great ENT cases were challenging problems of birth anomalies and other congenital disorders.

For T&As, we used the smooth agent halothane (plus nitrous oxide), breathing the child down, starting the intravenous, and intubating the trachea with deep halothane – no other drugs. We'd have the child deeply anesthetized for the adenoidectomy, as that's the most stimulating part of the procedure and requires deeper levels to prevent contraction of the pharyngeal muscles with the deeper dissection. We'd lighten the anesthetic for the more superficial part of the procedure, removal of the tonsils. As the surgeon was finishing, and drying up, we'd have the child at a light level of anesthesia, breathing on her/his own again. When the surgeon was finished, we'd turn the child on her/his side, for better drainage of secretions or blood from irritated tissues and slip out the endotracheal tube. With the smoothness of halothane, they didn't miss a breath. In the recovery area, we'd watch for a few minutes as they awakened, and had protective reflexes. As the child became reactive, we administered an opiate intravenously for comfort. These were wonderfully satisfying cases.

The toughest cases were repeated dilation of tracheal stenosis. These children had major breathing problems due to the great effort required to move air through the narrowed trachea. They periodically came in for tracheal dilation, which eased their breathing efforts. Unfortunately, with time, they re-stenosed, and thus had the procedure repeatedly. Because of the problems in their upper airway, at the end of the dilation, they all developed laryngospasm, far worse than what I'd seen in the baby in Denver after his eye examination. When the dilation was finished, we literally had to hold them and keep the endotracheal tube in their trachea until they were awake and could communicate. If we removed it even a tiny bit sooner, they had a laryngospasm that was impossible to treat with positive pressure or even with waiting until hypoxia and hypercarbia broke it. They'd need succinylcholine, and then we'd have to resume anesthesia and start over again. We learned to wait until they removed their own tube. Even then, we had to watch them like a hawk.

These were wonderful cases for residents. As we finished the program at LA, we were capable at pediatric anesthesia, especially if Digby had given us extra time in these more demanding rooms. We had to prove ourselves to gain that blessing.

Digby Leigh, Fearless Commander

Digby was about 5' 5" tall (165 cm) and 160 lb (73 kg). He was fearless and innovative, had a penetrating acid voice, and a good academic department. He'd try anything that might smooth and aid in anesthesia. Babies coming to surgery sometimes cried endlessly, and the nurses' aides couldn't calm them. Digby approached this in his usual experimental way. He had the babies breathe cyclopropane by mask until they were just unconscious; he then stopped the cyclo and permitted them to awaken. After a few ‘treatments' like that, most lay there rather groggily, and were quiet. Digby's fearlessness applied to surgeons, too. He certainly laid to rest at LA Children's the "Captain of the Ship" role that surgeons were slowly relinquishing.

One surgeon was a member of a long-standing well-known family. He complained during a case that my anesthetic was inadequate and demanded that the faculty attending come into the room to correct it. I don't recall the details of his complaint, but when Digby entered the room, the surgeon visibly blanched. Digby determined that the anesthetic was fine and then dismembered the surgeon. Digby told him that he came from a wealthy distinguished family, had no need to earn any money, and fumbled his way along as a pediatric specialty surgeon. He said that he was better off doing something else, and that he could learn medical expertise by watching this anesthesia resident perform superbly. Digby left, and I didn't hear anything from that surgeon ever again.

Some faculty don't effectively protect house staff. Digby never let even a supposed slight get by, and it was warming to us as temporary housestaff. It would have been easy for others to take advantage of our brief time there and our uncertainties, but there was never a hint of that with Digby around.

The recovery room at Children's was split between two floors, one part on the OR level for serious cases, and one a floor away for ‘easy' cases. As one resident finished a case with Digby and removed the endotracheal tube, Digby injected a small amount of succinylcholine into the intravenous line and clamped off the flow. If an airway problem occurred after extubation of the trachea, the intravenous line would be unclamped, and the child could be quickly relaxed and treated promptly.

Everything went smoothly. The succinylcholine wasn't needed, but Digby was distracted and didn't tell the resident about it. The resident took the child onto the elevator to go to the secondary recovery room. On the elevator, he saw that the intravenous wasn't running, so he unclamped it. Next he saw fasciculations and paralysis, and realized what had happened. He ventilated the child from there to the recovery room, where the paralysis receded within a few minutes. Luckily no disaster occurred.

When the resident returned to the operating room suite, I was there in the hall when he told Digby that he should have been told about the succinylcholine. Digby's response was, "Aw, that was a good experience for you." Today, even Digby wouldn't consider doing that.

Needless Delay in Routine Clinical Use of End-expired Carbon Dioxide

Modern monitors routinely provide valuable information via measurement of carbon dioxide in the expired gases. We had occasionally seen an expired carbon dioxide monitor at Colorado, but Digby used it routinely for critical cases. By fall 1960, Digby wanted it introduced into routine anesthesia care, but there were scoffers who delayed its introduction some 20 years (Smith, 1996). This delay, lasting until the late 1970s to early 80s, likely and unfortunately, resulted in deaths during episodes of malignant hyperthermia or problems with airways, because of the associated delay in detection, or with difficulties in management.

Landmark: Closed Chest Cardiac Massage, No More Scalpels

While I was in LA, a Los Angeles County Anesthesiology meeting in the fall of 1960 introduced the Johns Hopkins landmark study of closed chest cardiac massage for treatment of cardiac arrest (Kouwenhoven et al, 1960). Until then, cardiac arrest had to be treated by open chest cardiac massage, and a sterile scalpel had to be available in all critical locations.

About a month prior to that, while I was on overnight call at Children's, a family physician brought his several month old son to the emergency room. He had been having apneic spells, recently more frequently, known to be cardiac in origin. The emergency call physicians – surgery, anesthesia (me), pediatrics – discussed this with the father. About 5 a.m., the boy had another arrest. At that time, I was doing routine ‘checkup' rounds, to see that laboratory work was complete on the day's surgical patients. As I passed the ICU, a nurse called me in to check the baby. He was pulseless and apneic.

I opened his left chest with the ever available scalpel (careful not to sever an intercostal artery), and held a black rubber anesthesia mask to his face with my left hand. I performed cardiac massage right handed, while the ICU nurse manually ventilated his lungs. Within a minute, although his heart remained flaccid, he began to rouse and move around. Within another minute, the surgical resident appeared -- barely awake, disheveled, unshaven, in his scrub clothes. He took over the massage, while I intubated the trachea. The baby continued to respond physically, although his heart never contracted again. About 15 minutes after resuscitation began, the pediatric resident appeared -- clean shaven, hair combed, tie in place, white coat over his shirt. He looked a bit out of place, and even embarrassed. That response summarized a fundamental difference between medical- and surgical-related specialties. The latter routinely were forced to act quickly and be prepared for it. The former seldom had to ‘jump' to a problem and didn't expect to on a routine basis.