Chapter Eight: Denver Private Practice 1961-1966

Chapter 8 Sub-sections

The difference between academic teaching and private practice non-teaching hospitals is in part efficiency and that reflects income. The academic atmosphere focuses on the beginner in anesthesia to develop judgment, skills, and adaptation, especially with sudden changes in the patient or the anesthetic. The learning period is several years, with greater emphasis on complexities as skills and judgment develop. This takes time, and cases are generally longer. The non-teaching hospital focuses on efficiency and income, and that's become much more important with for-profit medicine, which is not a blessing. Even prior to the for-profit medicine era, as when I entered private practice, it was a considerable adaptation to be rapid and efficient, with cases immediately following one another.

I joined the Denver Anesthesiology Group, which consisted of Ed Heaton, Chuck McCrory, Lou Lopez, and me, a respected group among Denver anesthesia providers. We did pre and postop rounds on all our patients. We worked in multiple hospitals, and provided our own gas machines at each. We carried our own equipment, and washed it between cases --- laryngoscopes: several sizes for small and large patients, curved blade, straight blade; stylets and endotracheal tubes. I carried two sets of tubes, one set clear plastic, and the other, armored, in French sizes 12, 14, 16, … 40. Pat sewed a roll-up cloth carrier for the tubes, with a slot for each size. When I started a case, I rolled out the carrier and selected the best size tube, with the others ready in case I needed a different size.

At that time, Denver anesthesia in the central hospitals included the Metz group, started by C. Walter Metz, the pioneer anesthesiologist in Denver, who was President in 1952 of the American Society of Anesthesiologists; the ‘Girls' group', with Alice Smith, Katie Wood Payne, Margaret (Maggie) Mahowald, and Francie Sims; the group at Presbyterian Hospital, and other loosely organized or solo practitioners. The Girls' Group was an informal complimentary name that reflected their capability. They as individuals and as a group were respected for their consistent quality, and routinely provided some of the cardiac anesthesia for the strong group of cardiac surgeons, with John Grow, Art Prevedel, Chuck Demong, John ‘Bud' Wilson, and Bob Maloney.

When I started in private practice, ventilators were not easily available or efficient, so we hand-ventilated all patients by squeezing the reservoir bag. If the patient's breathing was not too depressed, s/he could breathe spontaneously, without our helping each breath by squeezing the reservoir bag. Most of the time, we assisted ventilation. If the patient's spontaneous breathing stopped, due to central nervous system depression or skeletal muscle paralysis, constant hand-ventilation was mandatory. When I needed both hands, as in pumping blood, or injecting extra drugs, I attached a length of breathing tube between gas machine and reservoir bag, and squeezed the bag either under an elbow, or between my knees. Later, mechanical ventilators permitted controlled ventilation in place of our hands and knees.

Obstetrical Salvation

In 1963, I provided general anesthesia with cyclopropane for a vaginal delivery at St. Joseph's Hospital, common practice at that time. When the baby was born, the excellent family practitioner, whom I knew, began the initial newborn care. I immediately observed, from chest movements, that the baby was trying to breathe but had a totally obstructed airway. The family practitioner suctioned the oral pharynx but knew no other methods of resuscitation. He recognized that he was in trouble, said that there was nothing else he could do, and could anyone help.

I told him to give me the baby, and set him on the tabletop of the Foregger anesthetic machine. Our chair in residency, Dr. Virtue, had triply emphasized to us in OB cases that we should always have infant resuscitation equipment set up in advance even if someone else was there to care for the newborn, for we were the best in airway management. This precaution paid off royally. I had an infant endotracheal tube and laryngoscope all ready. Direct laryngoscopy demonstrated a mucous plug totally occluding the opening of the trachea. It was easily suctioned. I ventilated the baby with oxygen (taken briefly from the mother), and there were no further problems. I had had to switch my anesthesia attention back and forth between mother and baby for several minutes. This cemented anesthesia relationships with that family practitioner and obstetrician.

Another birth, in December, was that of our daughter Gail Ann, at General Rose Hospital, always an exciting event.

Axillary Nerve Block with Brief Cardiac Collapse

I cared for a 17-year-old girl, providing an axillary nerve block via the peri-arterial injection of lidocaine for her surgery. Within less than a minute of finishing the injection, she began a high-pitched breathing sound, like laryngospasm. She lost her peripheral pulses, had no heart sounds, and looked gray. She did not convulse but did have cardiac arrest. I realized that she had lidocaine toxicity due to high blood levels.

I ventilated her by mask with 100% oxygen (the most important initial treatment) and the surgeon provided external cardiac massage --- thank God for Johns Hopkins research! She returned to consciousness and effective circulation within a minute or two, with amnesia for what had happened. She recovered quickly and had no complications.

Bier Block on the leg, with toxicity

While I was on call one winter night, a skier was brought to a Denver hospital for treatment of a fractured tibia. Until he fell, our patient had been drinking beer and eating hamburgers all afternoon during his ski runs. His stomach was therefore full of undigested food, and aspiration was a potential risk. Rather than use a general anesthetic, I decided to use a Bier block. After wrapping his leg from foot to groin, I inflated the tourniquet and injected lidocaine via an ankle vein.

After the orthopedist had reduced the fracture and placed the cast, it was time to deflate the tourniquet. Because the procedure had been brief, I was concerned that there might be too much remaining lidocaine in his leg veins, and that release of the full amount with tourniquet deflation might result in toxic blood levels. So I attempted to release small amounts at a time, by deflating the tourniquet for a minute or so. This was to let blood into the leg and wash some of the lidocaine into the general circulation, where it would in part be taken up by the liver and metabolized. I did this several times over, and then removed the tourniquet.

But I had missed an important consideration: even though the tourniquet was deflated, the firm wrapping around it prevented venous return to the general circulation. So he had arterial perfusion into his leg but essentially no venous drainage out of it, and no loss of lidocaine from his leg. When I removed the tourniquet, and a flood of lidocaine-containing venous blood roared into his general circulation, my patient suddenly changed.

He became apprehensive, and said, "Doc, I'm gonna die."

I knew immediately that this was lidocaine toxicity. Again, first was mask oxygen. His color, blood pressure and pulse were fine, and his EKG was normal. I repeatedly checked these. He continued stable, and after several minutes, he improved, but was still worried.

I asked him, "Do you need anything"? He said he really needed a cup of coffee. Against operating room regulations, I instructed the circulating nurse to bring a cup of hot coffee. That was a solid psychological boost, and from then on he did well.

These several cases underscore the need to monitor every case appropriately, have emergency equipment always set up for use, and take nothing for granted. The smoothest administration of anesthetic can lead to unexpected complications, and a disaster is generally due to not realizing the possibility and not anticipating such an event. These can start as mysteries and turn into disasters.

Heparin Failure on a Pump Case – Why?

During private practice in Denver, the cardiac surgeons were performing a mitral valve replacement on a 35-year-old woman. I injected the heparin into a peripheral intravenous line, and we started on cardiac bypass. Within a minute or two, the pump began to seize due to clotting of her blood. I injected more heparin, without correcting the problem. She was comatose afterwards due to blood clots in her brain, and died within a few days. We could not determine whether my injection missed the intravenous tubing, or whether the woman was resistant to heparin. I reviewed my approach to the injection into the peripheral line, but could not discover an error, as there was no fluid on the drapes under it.

Reflection

There must be many situations in which a physician performs a fatal error or comes close to it, saved only by pure luck, or by skilled help that wonderfully just happens to be available. In private practice, I was alone most of the time – always at night, and regularly so even in the daytime, as other anesthesia providers were generally busy with their own cases. I had enough unpleasantness like this and was pleased at any time to help others in treating unexpected patient problems. When an error occurs, or almost occurs, the savvy physician must recognize it, and learn from it.

Denver Anesthesia Practice

Better surgeons knew good anesthesia providers, and each cultivated the other. We went to multiple hospitals to work with preferred surgeons, and thus were assured of good surgical practice and good collections. I performed 1000 anesthetics per year, and had collection problems with about 5 patients per year. We had perhaps 15% charity work --- if our regular surgeon had a patient who could not pay, neither of us billed. I consistently earned about $3000/month.

Part of our practice was to help other hospitals get started. When Lutheran Hospital on the northwest side of Denver opened in 1964, it had surgeons but no dedicated anesthesia providers. Each week, one of our group (now up to six members with Ken Simpson and Joe Alanis) would provide anesthesia there for a day.

On one occasion, my operating room was diagonally across the hall from another case. Since the doors of both rooms were open, I could see some of what was going on over there. An older obese woman was having a vaginal hysterectomy. Her legs were in stirrups, and the operating table was tilted head down. The general practitioner anesthetist was giving open drop ether on a cone-shaped cotton mask with spontaneous respiration. Even then, that was an unbelievably outmoded approach. Trained anesthesia providers would have used an endotracheal tube and controlled the patient's ventilation. It was obvious from her chest and belly movements that her airway was partially obstructed. This was a formidable stress to her heart and lung function.

Fortunately the surgery was not prolonged. When I arrived in the recovery room a bit later, she was there, in florid pulmonary edema, with a cardiologist treating her. I knew the cause -- prolonged partial obstruction to her airway, so she needed much extra effort to breathe. The extra effort created a greater negative pressure in her lung's airways, leading to fluid movement from blood vessels into the air passages. Fortunately, she was recovering.

Another case: a 10-year-old boy at Lutheran Hospital underwent an evening appendectomy. I used mask anesthesia with nitrous oxide-halothane since he had been vomiting, as we then generally assumed that his stomach was close to empty, and, even if not totally, without increased pressure within it. As he began to emerge from anesthesia near the end of the procedure, he began to swallow. I knew that this meant gastric contents, so I deepened him, passed a stomach tube (an adult tracheal suction catheter #18 works best in this size patient), and suctioned liquid material. I pulled the suction catheter, awakened him, saw the usual smooth emergence of halothane, and had no problems.

However, a similar Lutheran Hospital case was a disaster, and there but for the grace of God ... Several weeks later, another anesthesiologist cared for a 10-year-old boy for an appendectomy using mask anesthesia for the same reasons that I had. At emergence, the boy either vomited or regurgitated solid material that obstructed his upper trachea, but low in the neck so that not even a tracheotomy was helpful. They could not restore an airway and he did not survive.

Art Prevedel – Astute Surgeon and My First Hero

Art Prevedel was particularly gifted: fast when needed, deliberate when the situation demanded, comprehensive, and not ego oriented. He and I did pediatric bronchoscopies together, and he arranged us as an efficient team after he saw how quickly I intubated the trachea. As he put it, why should he fumble around to get the bronchoscope into the trachea when I could do it in seconds?

I'd breathe the baby down with halothane to a deep level, spray the vocal cords and down the trachea with a 4% lidocaine spray to prevent laryngospasm and reflexes, expose the trachea, and place the tip of the bronchoscope into the top of the trachea. He'd take it from there. I'd ventilate via the oxygen flush button on the anesthesia machine to add positive pressure via the bronchoscope side arm, but carefully and just enough to gently raise the chest. If the procedure took a while, I'd add small doses of intravenous succinylcholine or have him quit for a few minutes to add more halothane. These cases did well, and I loved working as a team with him.

Art Prevedel saved the life of my patient at old Mercy Hospital when I introduced a potentially fatal air embolism. At that time, intravenous fluids were in glass bottles, and hurried infusion required increased pressure via the air vent to force fluid more quickly. Once the fluid was gone, the air pumped into the bottle could enter the patient's vein if you didn't stop the infusion. Art's procedure was a gastrectomy on a 37 year-old-man for carcinoma.

I fell behind on fluid replacement and added a pressure bulb that pumped air into the glass bottle of lactated ringer's solution to speed the infusion, confident that I would control the situation. Something distracted me and I suddenly heard the sound of air as coarse bubbling through the esophageal stethoscope. The bottle had emptied, and air was being pumped into the vein and on into the heart. I released the pressure and clamped the tubing, and warned Art that cardiac arrest was imminent. The heart was abruptly filled with air with an effect sort of like vapor lock in the carburetor of an old car. Effectively no blood can get through the heart and out to the body.

Art felt the heart through the diaphragm and noted the arrest. He incised the diaphragm and started manually pumping the heart, but said that it was empty --- the air in it created an empty bag, so that squeezing didn't push blood through. He needed added liquid within the heart. I hung another bottle of lactated ringers solution and again pumped it with a pressure bulb! Art felt the heart fill, he massaged it, and he felt it begin to beat strongly. Our patient had no complications and survived at least 15 years, apparently cancer free. My role postop, Art said, was to explain to the patient why he was in an ICU.

Art Prevedel was thoughtful and perceptive. Our daughter Mary was born seven weeks premature, a bit over 5 lbs., on May 21, 1965. She became jaundiced because her immature liver could not metabolize her extra bilirubin. The treatment of choice at that time was exchange transfusion to dilute the blood hemoglobin level.

There was a recognized mortality to this procedure, as the babies were delicate and stressed, the blood was cooler, and it was difficult to maintain the baby's normal body temperature. Art interrupted his clinical day to stay with Mary and her pediatricians during the exchange transfusion. Her pediatricians knew Art well and trusted him as a colleague. With his routine experience in hypothermia and cardiac surgery, he knew what to avoid and how to treat any problems. I didn't learn of his action until well afterwards. He didn't broadcast. Soon after this, fluorescent light on the skin was shown to diminish bilirubin, thus eliminating exchange transfusion as a treatment.

Home Care: Caudal Anesthesia

I cannot believe what we sometimes accomplished, more or less fearlessly, but prepared and safe. An anesthesia friend had just had a hemorrhoidectomy and was home, with terrible suffering, attempting that first bowel movement. My desperate friend asked me to relieve the pain for that first attempt with a caudal anesthetic. It was decidedly not routine to give anesthesia at a home, but we were accustomed to bringing anesthesia machines and other anesthetic paraphernalia to various hospitals and some dental offices. As routine precautions, that evening I brought a small oxygen tank and a means to ventilate the patient if necessary, various drugs, and monitoring apparatus. I placed the caudal solution into a most cooperative patient, and had excellent analgesia around the buttocks. Function was temporarily painless and things improved from then on.

Prolonged apnea with succinylcholine

In 1963, in private practice in Denver, I anesthetized a teen-aged girl on vacation from North Dakota. She was healthy and needed an appendectomy. At 10 p.m., I gave her thiopental and succinylcholine, and intubated her trachea. The case was finished in 45 minutes, but she wouldn't breathe on her own. I soon realized that she had the rare prolonged apnea following succinylcholine, due to absence of pseudocholinesterase. That meant that I had to hand-ventilate her until she spontaneously recovered muscle strength.

At that time there was no night time recovery room, no intensive care unit, and no automatic ventilator. So the surgeon, nurses, and I stayed in the operating room until she again breathed, about 5 a.m. There was no risk to her health as long as we maintained respiration and kept her warm in the cool operating room. When she suddenly moved and awakened at 5 a.m., she had no memory of the postoperative events, even though she had breathed nothing but oxygen, and the anesthetic drugs had easily been dissipated by midnight.

Awareness during anesthesia can be a problem --- in our Denver practice we tried to avoid awareness by partially but not totally paralyzing a patient during surgery. Thus, if the patient moved in any way, we knew that the level of anesthesia needed to be deepened. Even now I don't know why there was no awareness during the long wait, and am still surprised that she didn't remember at least something. We hadn't greatly hyperventilated her, as near as I could determine.

Practice in Denver had been interesting, varied, and at times unusual, but then my practice changed to Minnesota and the Mayo Clinic.

Travels with Art Prevedel – Move from Denver to Rochester

Art Prevedel and I traveled together on several occasions to visit practices in various areas around the country, to improve our approaches on heart cases that required perfusion pump bypass machines.

On one of our trips, in February 1966, we visited the Mayo Clinic in Rochester, Minnesota, for a meeting on cardiac surgery and visits to their surgical suite. Mayo was impressive, well organized, and productive. John Kirklin and Dwight McGoon were famous for Mayo Clinic's enviable success in open heart surgery.

During our visit, Emerson Moffitt, then chief of anesthesia at St. Mary's Hospital offered me an academic position, with the potential for teaching and research. Our entire family visited in the spring, by train from Denver (a wonderful way to travel), and stayed at Martha and Alan Sessler's home in northeast Rochester. Pat and I moved there in August 1966.

Mayo was a solid introduction to academia within a super organized large group practice. I began a 20 year career in neuroanesthesia, with every day challenges of placing a patient in the sitting position for surgery on the back of the skull or neck, carotid endarterectomies with measurements of regional cerebral blood flow and 16 lead EEG, intracranial aneurysms, and enough routine craniotomies to satisfy anyone. But, within 8 months, I was drafted for the Viet Nam conflict, a serendipitous move that began and focused my research future. Research, however, requires a mentor and control of ego.