been the only potential problem. Dr. Goodman had feared that the enormous bulk of fatty tissue would have absorbed such large quantities of the anesthetic agent that termination of the anesthesia would have been very difficult. But that had not proved to be the case. Despite the fact that the case had been prolonged the patient had awakened very quickly and extubation had been carried out almost immediately after the final skin suture had been tied.
The other two cases that morning had been very routine: a vein stripping and a hemorrhoid. The final case for Dr. Goodman, Berman, was to be a meniscectomy of the right knee and Dr. Goodman expected to be in his lab by 1:15 at the latest. Every Monday morning Dr. Goodman thanked his lucky stars that he had had enough foresight to have continued his research proclivities. He found clinical anesthesia a bore; it was too easy, too routine, and frightfully dull.
The only way he kept his sanity those Monday mornings, he’d tell his neighbor, was to vary his technique to provide food for his brain, to force him to think rather than just sit there and daydream. If there were no contraindications, he liked balanced anesthesia the best, meaning he did not have to give the patient some gargantuan dose of any one agent, but rather he balanced the needs by a number of different agents. Neurolept anesthesia was his favorite because in certain respects it was a crude precursor to the types of anesthetic agents he was looking for.
Mary Abruzzi returned with the endotracheal tube.
“Mary, you’re a doll,” said Dr. Goodman, checking off his preparations. “I think we’re ready. How about bringing the patient down?”
“My pleasure. I’m not going to get lunch until we finish this case.” Mary Abruzzi left for the second time.
Since Berman did not offer any contraindications, Goodman decided to use neurolept-anesthesia. He knew Spallek didn’t care. Most orthopedic surgeons didn’t care. “Just get them down enough so I can put on the Goddamn tourniquet, that’s all I care about” was the usual orthopedic response to the query about which anesthetic agent they might prefer.
Neurolept anesthesia was a balanced technique. The patient was given a potent neurolept, or tranquilizing agent, and a potent analgesic, or painkiller. Both agents provided easily arousable sleep as a side effect.
Dr. Goodman liked droperidol and fentanyl best of the agents cleared for use. After they were given, the patient was put to sleep with Pentothal and maintained asleep on nitrous oxide. Curare was used to paralyze the skeletal muscles for entubation and surgical relaxation. During the case aliquots of the neurolept and analgesic agents were used as needed to maintain the proper depth of anesthesia. The patient had to be watched very closely through all this, and Dr. Goodman liked that. For him the time passed more quickly when he was busy.
The OR door was opened by one of the orderlies helping to guide Berman’s gurney into room No. 8. Mary Abruzzi was pushing.
“Here’s your baby, Dr. Goodman. He’s sound asleep,” said Mary Abruzzi.
They put down the arm rails.
“OK, Mr. Berman. Time to move over onto the table.” Mary Abruzzi gently shook Berman’s shoulder. He opened his eyelids about halfway.
“You have to help us, Mr. Berman.”
With some difficulty they got Berman over onto the table. Smacking his lips, turning on his side, and drawing up the sheet around his neck, Berman gave the impression that he thought he was home in his own bed.
“OK, Rip Van Winkle, on your back.” Mary Abruzzi coaxed Berman onto his back and secured his right arm to his side. Berman slept, apparently unaware of the activity about him. The cuff of the pneumatic tourniquet was placed about his right thigh and tested. The heel of his right foot was placed in a sling and hung from a stainless steel rod at the foot of the operating table, lifting the entire right leg. Ted Colbert, the assisting resident, began the prep by scrubbing the right knee with pHisoHex.
Dr. Goodman went right to work. The time was 12:20. Blood pressure was 110/75; pulse was seventy-two and regular. He started an I.V. with deftness which belied the difficulties of handling a large-bore intravenous catheter. The whole process from skin puncture to tape took less than sixty seconds.
Mary Abruzzi attached the cardiac monitor leads, and the room echoed with the high-pitched but low- amplitude beeps.
With the anesthesia machine rigged and ready, Dr. Goodman attached a syringe to the I.V. line.
“OK, Mr. Berman, I want you to relax now,” kidded Dr. Goodman, smiling at Mary Abruzzi.
“If he relaxes any more, he’s going to pour off the table,” laughed Mary.
Dr. Goodman injected intravenously a 6 cc bolus of Innovar, the same droperidol and fentanyl combination that had been used as the pre-op medication. Then he tested the lid reflex and noted that Berman had already achieved a deep level of sleep. Consequently Dr. Goodman decided that the Pentothal was not needed. Instead he began the nitrous oxide/oxygen mixture by holding the black rubber mask over Berman’s face. Blood pressure was 105/75; pulse was sixty-two and regular. Dr.
Goodman injected 0.40 mg of d-tubocurarme, the drug which represents a debt modern society owes to the Amazon peoples. There were a few muscle twitches in Berman’s body, then relaxation followed; breathing stopped. The entubation was rapid and Dr. Goodman inflated Berman’s lungs with the ventilating bag while he listened to each side of the chest with his stethoscope. Both sides aerated evenly and fully.
Once the pneumatic tourniquet was cajoled into functioning, Dr. Spallek breezed into the room, and the case went rapidly. Dr. Spallek was into the joint in one dramatic slice.
“Voila,” he said, holding the scalpel in the air and tilting his head to admire his handiwork. “And now for the Michelangelo touch.”
Penny O’Rilley’s eyes rolled up inside of her head in response to Dr.
Spallek’s theatrics. She handed him the meniscus knife with a trace of a smile on her lips.
“Anoint my blade,” said Dr. Spallek holding the knife out for the resident to squirt irrigation fluid over its tip.
The knife was then inserted into the joint and for a few moments Dr.
Spallek rooted around blindly, his face upturned toward the ceiling. He was cutting by feel alone. There was a faint grinding sound, then a snap.
“OK,” said Dr. Spallek tightening his teeth, “here comes the culprit.”
Out came the damaged cartilage. “Now I want everyone to see this. See this little tear on the inside edge. That’s what’s been causing this chap’s problems.”
Dr. Colbert looked from the specimen to Penny O’Rilley. They both nodded approval while both secretly wondered if the little tear hadn’t been caused by the blind cutting with the meniscus knife.
Dr. Spallek stepped back from the table, pleased with himself. He snapped off his gloves. “Dr. Colbert, why don’t you close up. 4-0 chromic, 5-0 plain, then 6-0 silk for the skin, I’ll be in the lounge.” Then he was gone.
Dr. Colbert dabbed ineffectually at the wound for a few moments.
“How much longer do you estimate?” questioned Dr. Goodman over the ether screen.
Dr. Colbert looked up. “Fifteen or twenty minutes, I guess.” He palmed a pair of toothed forceps and took the first suture from Penny O’Rilley. He took a bite with the suture and Berman moved. At the same time Dr.
Goodman felt a tenseness in the ventilating bag when he tried to breathe Berman. He sensed that Berman was trying to breathe on his own.
Concurrently the blood pressure rose to 110/80.
“He must be a little light,” said Dr. Colbert, trying to sort out the layers of tissue in the wound.
“I’ll give him a bit more of this love potion,” said Dr. Goodman. He injected another full cc of Innovar, since the syringe with the Innovar was still connected to the I.V. line. Later he admitted that this could have been a mistake. He should have used only the analgesic, fentanyl.
The blood pressure responded rapidly and fell as Berman’s anesthesia deepened again. The blood pressure leveled off at 90/60. The pulse increased to 80 per minute, then fell to a comfortable 72 per minute.
“He’s OK now,” said Dr. Goodman.
“Good. OK, Penny, feed me those chromic sutures and I’ll get this joint closed,” said Colbert.
The resident made fine headway, closing the joint capsule and then the subcutaneous tissues. There was no
