Saturday, July 23, 2011

Sixth Chapter

Sixth Chapter
In which we are taken on a spectral tour of the OR suite

   David came to awareness in a swirling grey/white fog. Slowly, pixels of color started to appear, filling in a picture. It took awhile for the picture to resolve into something that David could recognize. He noticed that it was an OR and that Dr. Macintyre, his surgeon was in the scene. Although he could not recall their names, he also recognized Kerry, the nurse, and Carol the anesthetist. There was the long rectangular stainless steel box of the heart lung machine with its whirling roller pumps, rack of tubings and bags of fluid, and the two large diameter plastic tubes leading from the machine to the draped shape on the OR table. One tube was bright red, the other a dark red. David moved closer to the head of the table, and was quite surprised to see himself, face distorted by the breathing tube sticking out of his mouth and taped securely to his face. He reached out to touch the face on the table, but he felt nothing. The next thing that he noticed was the lack of other senses. The pain in his bones and joints was gone; he felt no laboring shortness of breath. These things had been his chief sensations for many years, and now they were gone.  He turned away from the OR table and passed right through the heart-lung machine without feeling it.

Looking around he expected to see everybody looking at him, but nobody noticed. He spoke out, but nobody heard him. David stopped in place and reassessed what he was seeing around him. The scrub nurse was passing sutures to Dr. MacIntyre; the other nurse was working on a computer next to a white board with tallies of several types of objects recorded. A man of his own age was tending the heart-lung machine and the anesthetist was concentrating on the wiggling lines on a monitor. And his body was on the table under the drapes and he was free of the effects of his Marfan’s Syndrome. While he was conducting this survey, he had drifted and he found himself passing through the door of the OR into the Hallway. Through the door, without opening it! David drifted as much as he directed his progress. He drifted through the wall into another OR, and as he assimilated what he was now seeing, he forgot all about what he had left behind in the open heart OR.

   In this OR, Dr. Gerald was resecting a colon. Dr. Gerald was the new junior partner of a general surgeon of long standing in the hospital who was planning to retire in a few years. Dr. Gerald was also just a year out of a colorectal fellowship, so he was in his first year of private practice and like many of his peers, was deeply in debt from his medical education. It was not uncommon for a young physician in Dr. Gerald’s position to be two to three hundred thousand dollars in debt. To compound his financial challenges he was also beginning a family and had just purchased his first home. He was taking on finishing off the basement himself, to make a family room, a spare bedroom and a bath. And that brings us to Tim, an OR Tech who used to work in home building as a framing and finish carpenter. Tim was filling the role of scrub nurse for Dr. Gerald. Dr. Gerald was quizzing Tim on the proper ways to put in framing and insulation against the cinder block walls of the basement. Tim did a lot of work on the side for many of the OR staff and doctors, everything from custom built cabinets to decks. The surgical procedure progressed, as both Tim and Dr. Gerald were in a groove, Tim being two steps ahead of Dr. Gerald in his mind as a really good scrub nurse should be. Dr. Gerald rarely had to ask for an instrument, as Tim already had it in his hand ready to pass it to Dr. Gerald. As their talk turned to two-by-fours, fiberglass batting, foam board and vapor barriers, Janet the circulating nurse gave Dr. Levin the anesthesiologist a look and rolled her eyes. “I feel like I’m trapped in an episode of Home Improvement or This Old House.” She opined.

   David felt compelled to explore, there was a feeling that he should be looking for something. He drifted over to the wall, and since it worked well on doors, he glided right through the wall. In the next room was Dr. Johnson, the senior surgeon at the hospital. It was said of Dr. Johnson “He’s an old dog who knows all the tricks, but more importantly, he knows which tricks actually work”. He was now repairing a routine Inguinal Hernia, or to be more exact, he was watching a senior resident do the actual repair. He was quite satisfied with his resident’s work having nurtured him through all the stages of a hernia repair previously.

   Dr. Johnson was heir to, and lived on his family’s farm, and though he didn’t farm it himself anymore, he still had plenty of stories to tell. One of his favorite subjects was his neighbor, Dewey, who was a deputy to the county sheriff. There had been many complaints about drunken drivers coming from a certain road house late at night, so Dewey had staked it out. He had his cruiser parked out of sight but where he had a good view of the parking lot. After a bit, a fellow came staggering out of the bar, and lurched over to an older Ford sedan. Leaning against the car, he began searching his pockets for his keys. Handkerchief, coins, pocket knife and comb clattered to the gravel. Finally, the keys materialized, only to be fumbled and join the rest of the contents of his pockets on the ground. Bending over to retrieve the keys, the man lost his balance, falling into the car, sliding down the fender, and joined his belongings scattered on the ground. He rolled over and got up on all fours and began to search for his keys. Finding them, he pulled himself up by the door handle of the car, which of course opened, causing him to fall to the ground again. Dewey watched amazed that this guy could even find his car let alone his keys. On all fours the man crawled into the car and began the process of getting up from the floor into the driver’s seat. Dewey winced as the struggle to get the key into the ignition commenced, involving two trips to the floor of the car to regain possession of fumbled keys. Dewey was paralyzed watching the spectacle. Finally, the key turned, the car started, lurched into gear, and wavered onto the road, tracing a weaving path. Dewey fired up the cruiser, lit the lights and followed on a slow speed chase. The man seemed to take no notice of cruiser, lights or siren for almost a mile, and then pulled over to the side uncertainly. Dewey got out and went over to the car, knocking on the window and motioning for the man to crank the window down, which the man did with surprising ability. Dewey expected to be knocked over by a powerful draft of fumes, but was surprised by the complete lack thereof. Still, he had the man get out of the car, which the man did with agility. Temporarily forgetting about asking for the man’s driver’s license, he had the man do a breathalyzer. The indicator on the breathalyzer showed nothing. “All right now” said Dewey, “what the blazes is going on here?” The man replied, “I’m the designated decoy”. Hearty laughter filled the OR.

   David looked around. Somehow he knew that whatever he was supposed to be looking for was not here, so he passed through a wall again. He was getting used to this new mode of getting around, and contravening the laws of physics was beginning to feel almost natural. He also became aware that his sensorium was limited to just sight and sound. No touch, no hot and cold, and most blessedly of all, no pain.

   In the next OR, two gowned, masked forms sat on stools looking into the eyepieces of a double headed microscope. David could make out that the microscope was perched over the head of a draped figure. The two figures were Carl, acting as scrub nurse and assistant, and Dr. Zietsev, an Otoneurologist. An Otoneurologist is an Ear Nose and Throat surgeon (aka Otolaryngologist) further specialized in disorders affecting nerve conduction in hearing loss. Rounding out the team in the OR was Karen, circulating nurse, and Dr. Prakash, anesthesiologist. They were in the middle of resecting an acoustic neuroma, a benign tumor of the acoustic nerve. While not malignant (cancerous), an acoustic neuroma has some very debilitating symptoms and effects: Loss of hearing on the affected side, disturbed balance and gait, vertigo causing nausea and vomiting, loss of sensation in and around the mouth on the affected side, and sometimes a loss of swallowing reflexes causing gagging. Intracranial pressure may be increased, causing headache and altered level of consciousness. Increased Intracranial pressure can be lethal. Surgery for the condition involved drilling out the mastoid bone ( the bump behind the ear ) to expose a space called the vestibule. This leaves a paper thin layer of bone over the brain, and comes very close to the innermost structures of the ear. The facial nerve shares the vestibule with the acoustic nerve and damaging it can lead to paralysis of that side of the face. Needless, to say this is a very delicate and highly demanding procedure. There are only a handful of surgeons in the USA who do the procedure, which can take eight or more hours in the OR. 

  Given the difficulty of the procedure, Dr. Zietsev was very particular about the personnel on his team. He long ago settled on Carl as his scrub, even taking Carl to his lab to teach him to drill out a mastoid, using actual mastoid bones from cadavers. This enabled Carl to anticipate his every move, and have the appropriate instrument into his hand without discussion, and to also aid whenever an extra hand was needed again without the necessity of direction from Dr. Zietsev. Karen came along with Carl, the two being a team unto themselves.

   Zietsev was just as talented musically as he was surgically. His passion was for choral works, and he was director of the University Choir. He made every new face entering his OR sing, as he was always looking for new talent. Carl failed to impress, but Karen had a great contralto and soon was part of the choir. Zietsev had even been a guest conductor with the City Symphony last summer. He played classical music in the OR, and had even gotten Carl interested in Mozart and Bach, despite Carl’s taste for Steely Dan, Supertramp and the Doobie Brothers.

   David felt the need to push on, to find that something that seemed to be his purpose. Drifting through the door, he crossed the hallway and entered the OR opposite.

   Music blared at a high volume; Bruce Springsteen’s Born To Run. This was the room of Dr. Gatling, Orthopedic surgeon specializing in total joint replacements. Born to Run was his closing music. During his surgeries, his taste was quieter, and more eclectic. You might hear Astrid Gilberto doing The Girl from Ipanema followed by Count Basie followed by Stevie Nicks. Gatling was a very talented instrumentalist, specializing in guitar (acoustic steel and gut string, electric and slide) and reeds (baritone, tenor, alto sax, clarinet and flute). Gatling had gone to college, med school and residency in Philadelphia and had worked on the side as a studio musician at Spectrum Sound on Broad Street. He played on many of the Gamble and Huff productions of Harold Melvin and the Blue Notes, the O’Jays, Lou Rawls, and a Philadelphia favorite, Patti LaBelle. He fronted a band of hospital personnel that called themselves “Malpractice”.

   Gatling was telling a story on George, his OR tech. Back in the old days when Gatling was a brand new orthopedic surgeon and had to cover call at all hours, he was called in late, late one night for a fractured hip. George was on call that night along with Meg. In those days women still wore scrub dresses in the OR. When Gatling and George arrived, the OR was out of scrubs for men, so with red faces they donned scrub dresses. With Meg and the anesthesiologist barley muffling  laughter, and  manly legs on display, things moved on. It turned out that the patient was an older gentleman who had an above the knee amputation on the side where his hip was broken. He had been able to walk on a prosthetic leg quite well, and felt that he would be able to do so again when his hip was fixed. The best way to fix the hip at that time was an Austin-Moore.

   Now a broken hip is actually a fracture of the femur (thigh bone) at the narrow neck where the ball of the hip joint attaches to the shaft of the femur. The ball on the end of the femur then fits into a socket of the pelvis to make the complete joint. To do an Austin-Moore, the whole end of the femur is trimmed off and the prosthesis, which is a ball on the end of a spike shaped to fit the shaft of the femur, is pushed down the hollow shaft along with some cement. The cement is basically a putty of methacrylate which is the same thing that super glue is made of. The ball is sized to fit the socket, and all is put back together. Now when the procedure got to the point where they were measuring for the prosthesis, Gatling and George discovered that the spike of the prosthesis was longer than the gentleman’s femur which had been shortened by his amputation. What to do, what to do? Gatling took the prosthesis, broke scrub, leaving George to watch over the open incision  keeping everything sterile. Gatling went down to the maintenance department of the hospital. Of course, maintenance was locked up, and security had to be summoned to open it for Gatling. Imagine the security guard answering a call and finding a burly man dressed in a scrub dress holding a silvery object that looks something like an Indian war club. Using the tools in the maintenance workshop, Gatling cut the spike off to size, filed it smooth, went over it with emery cloth to put a polish on it, and returned to the OR. Meg washed the Austin-Moore several times with iodine impregnated scrub brushes, the same ones used to scrub the hands and arms of the surgical team. She put the custom tailored prosthesis in the autoclave, and ran a double length cycle where pressurized steam at 273 degrees farenheit made sure it was sterile. Gatling rescrubbed, George gowned and gloved him and the procedure was completed in more or less the normal manner. The story got grins from all the team and George and Gatling did a knuckle bump.

   Growing frustrated at not finding the thing he was looking for, David drifted through the wall and found himself just outside the fourth floor, suspended in the air. Looking around, he felt that he was getting closer. He began to move upwards, gaining speed, and his vision narrowed. It began to be pixilated again, a darkness forming in the bright blue sky, and David passed into the realm that no one has ever returned from.

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