halothane, introducing it to the medical community in the lead article of the New England Journal of Medicine, and then walking up to receive his Nobel prize in the same tuxedo he had worn when he was married.
Dr. Billing was a damned good anesthesiology resident, and he knew it.
In fact, he thought most everyone knew it. He was convinced he knew as much anesthesiology as most of the attendings, more than some. And he was careful, very careful. He had had no serious complications as a resident, and that was indeed rare.
Like a 747 pilot, he had made himself a checklist, and religiously he adhered to a policy of checking off each step of the induction procedure.
This meant having Xeroxed off a thousand of the checklists and bringing a copy along with the other equipment at the start of each operation. By 7:15, the anesthesiologist was right on schedule at step number 12: that meant hooking up the rubber scubalike tubing to the machine. One end went into the ventilating bag, whose four- to five-liter capacity afforded him an opportunity to inflate forcibly the patient’s lungs at any time during the procedure. The other end went to the soda-lime canister in which the patient’s expired carbon dioxide would be absorbed. Step number 13 on his list was to make sure the unidirectional check valves in the breathing lines were lined up in the right direction. Step number 14
was to connect the anesthesia machine to the compressed air, nitrous oxide, and oxygen sources on the wall of the OR room. The anesthesia machine had emergency oxygen cylinders hanging from the side, and Dr.
Billing checked the gauge pressures on both cylinders. They were fully charged. Dr. Billing felt fine.
“I’m going to place some electrodes on your chest so we can monitor your heart,” said Gloria D’Mateo while pulling down the sheet and pulling up the hospital gown, exposing Nancy’s midriff to the sterile air. The gown just barely covered Nancy’s nipples. “This will feel cold for a sec,”
added Gloria D’Mateo as she squeezed a bit of colorless jelly onto three locations on Nancy’s exposed lower chest.
Nancy wanted to say something, but she couldn’t deal rapidly enough with her ambivalent attitudes about what she was experiencing. She was grateful, because it was going to help her, or so she had been assured; she was furious because she felt so exposed, literally and figuratively.
“You’re going to feel a little stick now,” said Dr. Billing, slapping the back of Nancy’s left hand to make the veins stand out. He had placed a piece of rubber tubing tightly around Nancy’s wrist, and she could feel her heart beat in the tips of her fingers. It was all happening too fast for Nancy to assimilate.
“Good morning, Miss Greenly,” said an ebullient Dr. Major as he whisked through the OR door. “I hope you had a good night’s sleep. We’ll get this affair over with in a few minutes and have you back to your bed for a restful sleep.”
Before Nancy could respond, the nerves from the tissues on the back of her hand became alive with urgent messages for her pain center.
After the initial thrust, the intensity of the pain increased to a point and then dissipated. The snug rubber tourniquet disappeared, and blood surged into Nancy’s hand. She felt tears well up from within her head.
“I.V.,” said Dr. Billing to no one, as he made a black check next to number 16 on his list.
“You’ll be going to sleep shortly, Nancy,” continued Dr. Major. “Isn’t that right, Dr. Billing? Nancy, you’re a lucky girl today. Dr. Billing is number one.” Dr. Major called all his patients girls no matter what age they were. It was one of those condescending mannerisms he had adopted unquestioningly from his older partner.
“That’s correct,” said Dr. Billing, placing a rubber face mask on the anesthesia tubing. “Number eight tube, Gloria, please. And you, Dr.
Major, can scrub; we’ll be ready at seven-thirty sharp.”
“OK,” said Dr. Major, heading for the door. Pausing, he turned to Ruth Jenkins, who was setting up the Mayo stand with instruments. “I want my own dilators and curettes, Ruth. Last time you gave me that medieval rubbish that belongs to the house.” He was gone before the nurse could answer.
Somewhere behind her, Nancy could hear the sonarlike beep of the cardiac monitor. It was her own heart rhythm resounding in the room.
“All right, Nancy,” said Gloria. “I want you to slide down the table a bit and put your legs up here in the stirrups.” Gloria grasped Nancy’s legs in turn under the knees and lifted them up into the stainless steel stirrups.
The sheet slid between Nancy’s legs, exposing them from mid-thigh down. The lower part of the table fell away, and the sheet slid to the floor. Nancy closed her eyes and tried not to picture herself spread-eagled on the table. Gloria picked up the sheet and haphazardly put it on Nancy’s abdomen so that it draped between her legs, covering her bloodied and recently shaved perineum.
Nancy wanted to be calm, but she was getting more and more anxious.
She wanted to be grateful, but the tide was swinging more and more in the direction of undirected anger and emotion.
“I’m not sure I want to go through with this,” said Nancy, looking at Dr.
Billing.
“Everything is just fine,” said Dr. Billing in an artificially concerned tone of voice, while checking off number 18 on his list. “You’ll be asleep in a jiffy,” he added, while holding up a syringe and tapping it so that the bubbles all fled upward to the room air. “I’m going to give you some Pentothal right away. Don’t you feel sleepy now?”
“No,” said Nancy.
“Well, you should have told me,” said Dr. Billing.
“I don’t know how I’m supposed to feel,” returned Nancy.
“It’s all right now,” said Dr. Billing, pulling his anesthesia machine close to Nancy’s head. With well-rehearsed adeptness, he attached his Pentothal syringe to the three-way valve on the I.V. line. “Now I want you to count to fifty for me, Nancy.” He expected that Nancy would never get past fifteen. In fact, it gave Dr. Billing a certain sense of satisfaction to watch the patient go to sleep. It represented repetitive proof for him of the validity of the scientific method. Besides, it made him feel powerful; it was as if he had command of the patient’s brain.
Nancy was a strong-willed individual, however, and although she wanted to go to sleep, her brain involuntarily fought against the drug. She was still audibly counting when Dr. Billing gave an additional dose of Pentothal. She said twenty-seven before the two grams of the drug succeeded in inducing sleep. Nancy Greenly fell asleep at 7:24 on February 14, 1976, for the last time.
Dr. Billing had no idea this healthy young woman was going to be his first major complication. He was confident that everything was under control The list was almost complete. He had Nancy breathe a mixture of halothane, nitrous oxide, and oxygen through a mask. Then he injected 2
cc’s of a 0.2 percent succinylcholine chloride solution into Nancy’s I.V. to effect a paralysis of all her skeletal muscles. This would make the placement of the endotracheal tube in the trachea easier. It would also allow Dr. Major to perform a bimanual exam, to rule out ovarian pathology.
The effect of the succinylcholine was seen almost immediately. At first there were minute fasciculations of the muscles of the face, then the abdomen. As the bloodstream sped the drug throughout the body, the motor and end plates of the muscles became depolarized, and total paralysis of the skeletal muscles occurred. Smooth muscles, like the heart, were unaffected, and the beep from the monitor continued without a waver.
Nancy’s tongue was paralyzed and it fell back, blocking her airway. But that didn’t matter. The muscles of the thorax and abdomen were paralyzed as well, and any attempt at breathing ceased. Although chemically different from the curare of the Amazon savages, the drug had the same effect, and Nancy would have died in five minutes. But at this point nothing was wrong. Dr. Billing was in total control. The effect was expected and desirable. Outwardly calm, inwardly very tense, Dr.
Billing put down the breathing mask and reached for the laryngoscope, step number 22 on his list With the tip of the blade, he pulled the tongue forward and maneuvered past the white epiglottis, while he visualized the entrance to the trachea. The vocal cords were ajar, paralyzed with the rest of the skeletal muscles.
Swiftly Dr. Billing squirted some topical anesthetic into the trachea, followed by the endotracheal tube. The laryngoscope made a characteristic metallic snap as Dr. Billing folded the blade onto the handle. With the help of a small syringe, he inflated the cuff on the endotracheal tube, providing a seal. Quickly he attached the tip of the rubber hose, without the face mask, to the open end of the endotracheal tube. As he compressed the ventilating bag, Nancy’s chest rose in a symmetrical fashion. Dr. Billing listened to Nancy’s chest with his stethoscope and was
