It was a sunny morning in July and I was scheduled at the outpatient center with the oral and maxillofacial surgeons for teeth extractions. One of my patients was your son, an athletic teenager, whose only medical history was asthma. According to you and him, he had not experienced any recent asthma attacks, and had never been hospitalized or intubated for one. In terms of breathing, he said he felt ‘perfectly fine’ for many years. The last time he took his inhaler was yesterday prior to exercising. He had not experienced any upper respiratory infections recently and was not having any difficulty breathing today. I placed my stethoscope on his chest and heard clear breath sounds. Reassured, I proceeded to finish setting up the operating room.
Confession: there are many risks and side effects of anesthesia, and we don’t always mention all of them — especially to the young, healthy patients that come for same-day surgery. The most common risks are sore throat (from the endotracheal tube), nausea and vomiting (from the anesthetic medications and the nature of certain surgeries), and short-term memory loss (also from the anesthetic agents). The major ones are very rare and include bronchospasm (when your airways close), heart attack, stroke, severe allergic reactions leading to cardiovascular collapse, and subsequently, death. I spoke to you about the common risks and mentioned your son’s slightly higher risk of an asthma exacerbation under anesthesia. You and him expressed understanding.
As I was setting up the operating room for your son, I thought about giving him an albuterol treatment just in case. His history did not suggest that he would be at high risk for an asthma exacerbation, and he did not bring his own inhaler. I thought about all the patients similar to him who did just fine without taking their inhaler on the day of surgery. So I decided against charging him extra money for the inhaler and proceeded to the operating room.
We planned to place a nasal endotracheal tube because the oral surgeons needed access to the mouth. On induction of anesthesia, we made sure to keep him very deeply anesthetized to avoid the stimulation associated with airway instrumentation. I obtained a perfect view of the trachea and proceeded to place the nasal tube. His airways immediately closed and we were unable to ventilate him. At this time, his oxygen saturation dropped significantly. We called for help and opted to skip the nasal tube as oral intubation is easier, especially in an emergency setting. After the oral endotracheal tube was placed, we were hardly moving any air at all as his hyper-reactive airways had completely shut, preventing vital gas exchange in the lungs. His oxygen saturation continued to drop, and we saw (and heard) the particularly ominous sign of a decreasing heart rate. I internally panicked. After multiple interventions including a deeper level of anesthesia, inhaled albuterol through the endotracheal tube, and IV medications to open up his airways, we were finally able to ventilate, and his heart rate and oxygen saturation increased appropriately. After a few minutes, my own heart rate and breathing stabilized.
The practice of anesthesia is often compared to flying a plane. Anesthesiologists are compensated for our training when things go wrong — for plan B, C, and D when plan A fails. Adverse events are more likely to occur on takeoff (induction of anesthesia) and landing (emergence from anesthesia). Sometimes complications occur in the middle of surgery and include major blood loss, accidental extubation, and pulmonary embolism to name a few. Although rare, when these major events do occur, they can be devastating and everyone in the operating room looks to you to rectify the situation. It is for this reason that anesthesiologists have become the pioneers in patient safety. As one graduates from timid intern to senior resident, the level of personal responsibility significantly increases. I experienced a similar case of bronchospasm early in my residency. I had practiced a simulation of the situation but other than that, I had no idea what I was doing and looked to my attending for help. It is interesting to note that early on, residents are mostly concerned about their own performance during a crisis. However as we go through residency, the internal thought process becomes less about personal performance and more about teamwork and the overall safety of the patient.
When I heard your son’s heart rate go down, I admit that I experienced a moment of mental paralysis. Our conversation from the pre-operative area flashed through my mind. I mentioned to you and him that he could have an asthma attack during the anesthetic, but I did not expect it to happen. I thought about what I would have to tell you if things did not improve — that God forbid we had to do chest compressions on your son because he had a rare complication during a surgery that could have potentially been done in a dentist’s office. I’m sorry that your son experienced a life-threatening complication when all he did was come to have his wisdom teeth removed. I am sorry that I did not listen to my instinct and give him albuterol before putting him under anesthesia. It may not have prevented the adverse event, but it would have cleared my conscience.
We almost expect adverse events to happen in the sick, elderly patients, especially the ones with significant cardiopulmonary disease. What we don’t expect — the severe bronchospasm in your teenage son, or the cardiovascular collapse of a healthy, pregnant woman from an embolism — is what leaves the deepest scars on our conscience and simultaneously makes us more competent physicians. I’m sorry about what happened to your son under anesthesia. You may never know this, but because of him I am a better doctor — and for that I would like to tell him, thank you.