As part of the routine scut of the overnight call team, I was sent up to the floor to preop an add-on for the next day’s OR schedule.
The Preoperative Anesthesia Assessment form has tidy little boxes for cardiac, pulmonary, renal, hematologic and an assortment of other complaints, and spaces for height, weight, allergies and personal or family history of untoward reactions to anesthesia. I put a single slash through the box on the dry-erase board in the operating room, wrote my initials next to it and took the elevator upstairs. I was gloriously happy when I flipped to the “Surgery Reports” section of the chart: two prior surgeries this admission, which meant two prior anesthetics, which meant the preop was already done; I needed only to write a quick update, copy down today’s labs, listen to his heart and lungs and get the consent signed and then I could check my email, call my husband or go to bed.
The yellow-bordered Anesthesia paperwork was easy to find. Twenty-two years old. Intravenous drug abuser. Massive stroke requiring brain surgery. Permanent feeding tube and tracheostomy. Still unresponsive two weeks later.
Needle passes through unsterilized skin had easily introduced bacteria into his blood, and those bacteria had latched on to the irregular surfaces of the valves on the right side of his heart, the place to which all veins eventually drain. Here they reproduced and formed a mass, unaffected by the slowly passing flow of blood into his lungs. As he ignored the fever, the tiredness, in his quest for more, a little chunk flicked off of the mass of bacteria and floated easily through the small hole between the right and left sides of his heart, a hole he never knew he had, a hole that a third of us have if we are inspected at autopsy, and from the left side of his heart this ball was easily ejected by the muscular force of his left ventricle up into his aorta, taking a quick upward turn at the carotid artery, and traveling onward until the vessels grew small enough that it could lodge itself and rest, quietly but instantly occluding blood flow to half of his brain.
And that was it. I wrote down the last few days of events, the most recent vital signs, labs, medications and chest x-ray and walked into the room. He was thin, pale and young, unclothed except for a hospital gown. His hair was clipped close from the decompressive craniotomy he needed to release the pressure in his brain after the stroke. I called his name. Nothing. I stepped forward and tapped his arm. His deep brown eyes fixed on mine. Inside there was nothing. I stood there, frozen, doom impending, tears forming deep inside, far from my eyes.
His mother and brother entered the room. I listened to his heart and lungs and explained the plan for anesthesia. “I won’t be taking care of him tomorrow. I’m just here to make sure we know everything we need to know to take care of him safely, to answer any questions you have and to sign the consent form with you.” His mother was a well-dressed, calm, attractive white woman around fifty. The brother was jumpier and stared at the man on the bed, but asked the right questions and was polite.
I filed the signed consent and the updated preop back into the chart and headed for the elevator. The world closed down. At home my boys were in bed already, Eli in his crib with the blanket wrestled into the corner, Keenan upstairs in his bed, tightly clutching tiger and doggie in his hands, with his prized new poster of the solar system hanging nearby. My boys were so small, so perfect, each an entire world, a microcosm that I carried with me everywhere. My patient’s mother had this once: two small, perfect boys, safe in their beds.
I was so suddenly, desperately and completely sad. I am simply not capable of imagining what she feels. Just a slice of it hurts too much. Back downstairs, I sat still and silent at the computer desk until my next case. I called home, told my husband I wanted to curl up on the couch in crappy old sweatpants and the most depressing movie I could imagine. He told me everything was fine, the boys were asleep, please don’t dramatize, I’ll see you in the morning.
I took over for a cardiac case where the surgeons were replacing heart valves chewed up by a rare metastatic cancer. The patient came off of cardiopulmonary bypass without a hitch, my attending was smart and kind, and we were done dropping him off in the Intensive Care Unit by midnight. I was sound asleep ten minutes later in my call room, and awoke nearly seven hours later to my alarm. That was a good night, those consecutive hours of sleep.
When I got home, the boys were perfect. Keenan had written “1+1=2” “2+1=3” “3+1=4” and so on up to fourteen on his easel. Eli’s clear blue eyes lit up when he pushed the button on my coffeemaker and it turned a satisfyingly bright red. I read books and snuggled with Keenan on the couch while Eli ran circles around the house. After dropping Keenan off at pre-K (infinitely differentiated from preschool in his mind: “preschool is for three-year-olds.”), I took Eli to “tempo time” at the library.
Time alone with the second child is rare and precious, so when I sleep on call and Keenan is excited to go to school, I keep my toddler home and relish the time I have with only him. Enter tempo time, one of several frequent offerings at my town’s public library’s children’s section, the perfect mom-and-toddler activity for a rainy Tuesday. I parked my comfortable car with two meticulously installed carseats amidst a sea of minivans, SUVs and wagons. We joined the procession into the packed function room in the library’s western wing. I counted the five-hundred-dollar strollers. Whole grain puffs and organic fruit snacks were clutched tightly in sticky hands. Nannies, mothers and grandmothers chased adorably dressed toddlers into the room where Roberta the queen of tempo time sat on the rug with guitar in hand. It was 10:57. I picked a spot along the wall and Eli sat in my lap. From my perch it seemed like everyone was looking at everyone else, hoping theirs would be the most perfect toddler at tempo time.
What am I doing? Really, tempo time? Roberta started, everybody clapped their hands and tapped their feet and swish-swish-swished and beep-beep-beeped along in rhythm. You library-music-people always start with the same song. How much is the library paying this lady anyway? For “Wheels on the Bus?” The woman to my left along the southern wall had three children under four dancing and clapping and her belly swelled with her fourth. I hope she is having fun, because she must not be able to have much fun generally. She glanced up. A tall, handsome policeman had entered through the far door. “Look, it’s Uncle Charlie!”
The three children waved at their uncle who had taken the time to stop by the library to see them, and with one glance at his proud face I melted. Eli chewed on his maraca and giggled and walked back into my lap and hugged me, his oversized blonde head melting into my shoulder. It was all okay. The Armenian grandmas and the stay-at-home-moms and me, post-call and a little tired, we were all there for the same reason. It was all we could do, to love them infinitely and try to do everything right. There was nothing else, nobody was best dressed and nobody had the healthiest snacks. It was just Roberta and the thirty dancing toddlers and Eli, who was too young to do the hokey pokey on his own but squealed when I spun him full circle on the carpeted floor.
Felicity Billings is an anesthesiology resident who blogs at One Case at a Time.
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