ADRENALINE: New 2013 edition by John Benedict Page A

job sound easy. It’s not. I’m not sure I’d ever want to do it. But, consider the bread-and-butter surgeries—the hernia repairs, the knee arthroscopies, the gallbladder removals, and so on, that make up ninety percent of all operations. The likelihood of the surgeon inflicting a mortal wound during one of these procedures is extremely remote.”
    “Why do you say that?” Rusty asked.
    “Well, because the area being operated on is far from any vital organ or large blood vessel,” Dr. Landry continued. “And that’s not to say all surgeons are perfect and don’t botch things up. On the contrary, mistakes do happen.”
    “You mean like amputating the wrong leg or something.” Rusty thought Dr. Landry seemed a bit touchy in this area; perhaps he was jealous of the surgeons.
    “Exactly,” Dr. Landry went on, “although that represents an extreme case. Sometimes hernias need refixing in several months or ear tubes fall out. The point is that the mistakes almost never cause immediate loss of life or brain damage.”
    “OK, I get it. But what makes anesthesia so different?”
    “Glad you asked.” Dr. Landry paused to take a bite of his sandwich. “Putting someone under a general anesthetic is completely different. Now,
every
case carries with it a small, but real risk of death or brain damage. You can die from anesthetic complications just as easily going to sleep for a five-minute D&C as you can for a five-hour spine fusion.”
    “Jeez, that’s comforting. Good thing no one knows that.”
    “Rusty, it doesn’t mean that being anesthetized is incredibly dangerous. It’s not. In the hands of a competent anesthesiologist, it’s very safe, carrying a risk similar to driving to the hospital. The point is that a general anesthetic involves the perfusion of all the vital organs; it’s not a peripheral procedure. Didn’t they teach you anything about perfusion in med school?”
    “S-sure,” Rusty stammered, suddenly trying to buy time. “It’s, uh, means getting blood flow to the tissues.” Typical attending—they’re all alike. Just when he thought he was away from the Med Center.
    “Right,” Dr. Landry said and smiled. Rusty relaxed a bit and took another bite of his rapidly disappearing sandwich. “Now what’s the purpose of having tissue blood flow?” Dr. Landry asked.
    “Well, the tissues need oxygen.”
    “Exactly. You
have
been paying attention in school. Oh, that reminds me of the old joke. What’s the deadliest substance known?”
    “Uh, I’m not sure.”
    “Oxygen, of course. It kills in levels as low as one part-per-billion.”
    “Hmmm . . .” Rusty didn’t get it, but vowed to work on it later.
    “Anyway, here’s the important part. What can disrupt tissue oxygen delivery or perfusion?”
    “Well let’s see.” Rusty put on his best studious look as he thoughtfully sipped his Coke. “If there’s a cardiac or BP problem, not enough blood will be pumped. That’d mess up perfusion.” Rusty suddenly realized where Landry was going with this. “Or if the patient’s not breathing, his O-two intake will stop.”
    “Precisely!” Dr. Landry beamed. “And this is what we deal with in anesthesia. Any airway or blood pressure problem can deprive the heart or brain of oxygen with disastrous results in minutes.”
    “When we put someone to sleep, what’s the first drug we give them?”
    “The white stuff, uh, Diprivan?”
    “Right. Diprivan, otherwise known as propofol. They lose consciousness quickly and then they don’t breathe, so we start ventilation by mask.”
    “What’s the problem?” asked Rusty.
    “What if you can’t ventilate them with the mask?” Dr. Landry countered.
    “Why wouldn’t you be able to? Anyway, then you could just intubate them with the endotracheal tube, right?” Rusty asked.
    “Right, but you’re getting ahead of yourself. Which drug did we give next to facilitate the intubation?”
    “The muscle relaxant, succinylcholine,” Rusty