Real Stories

It was nearing the end of a busy twelve hour shift on the Labour Floor as the anesthesiologist on call. The charge nurse informed me that a young woman, 32 weeks pregnant had just been transferred to our tertiary obstetric unit from a small hospital. She had pre-eclampsia, which is a serious complication of pregnancy. Her blood pressure was very high at 180/120, she was complaining of headache and the blood tests showed that her blood clotting was abnormal. The obstetrician planned to deliver her baby by cesarean section, since this was the best way to control her high blood pressure.

I visited her in her labour room to assess her and to discuss the anesthetic with her. In most cases, it is preferable to give either an epidural or spinal anesthetic for cesarean section. However, it is unsafe to do this when the blood clotting is abnormal, since blood may collect around the spinal cord. I would have to give her a general anesthetic.

My concern increased when I saw her. She was quite overweight on a short frame. I chatted with her obtaining her medical history. She was still quite dazed by the turn of events had taken, since 24 hours ago she had felt fine. I asked her to open her mouth wide, one way the anesthesiologist has to check how easy it would be to intubate. She opened her mouth no more than an inch and a half, saying that was all she could manage with the pain in her joints (TMJ syndrome). She was complaining of quite a severe headache and asked to be given something for it. I ordered a type of intravenous pain killer that works rapidly but does not cause nausea.

I prepared the operating room by setting up a special monitor that would give me beat-to-beat readings of her blood pressure. Women with preeclampsia often have wild swings of blood pressure under anesthesia. Therefore one has to know immediately what it is in order to correct it with medication. Aside from her blood pressure, my main concern was her airway. When a patient is given anesthetic medications, normal breathing stops. The anesthesiologist then becomes responsible for ensuring that her lungs receive oxygen by placing a small tube, an endotracheal tube, in the windpipe and mechanically inflating the lungs. Usually this is routine. In this patient, I knew it would be a significant challenge - if I failed to do it quickly, it could be life threatening, both for her and the baby, who depends on the mother for oxygen supply. I planned to sedate her lightly and gently introduce the tube when she was still semi-awake and breathing on her own.

She was wheeled in on a stretcher to the Operating Room. The nurses helped her to move over to the narrow operating table. I placed some folded sheets under her neck and shoulders to put her in the best possible position to see the vocal cords when inserting the endotracheal tube. Despite the late hour in the day, a number of people materialized to help and to watch her anesthetic - the anesthesia resident-in-training, a first-year medical student considering a career in anesthesia, and a family doctor who was thinking of doing some anesthesia training.

Just when she was settled on the operating room table, events began to unfold very quickly. Without warning, she began to have a violent grand-mal seizure that rendered her unconscious and stopped her breathing. This is one of the most feared and serious complications of preeclampsia. It became my responsibility, and mine alone, to ensure that the seizure was terminated and that she received oxygen quickly. Not only was her life at stake, but that of the unborn baby. Quickly the sedative medication to end the seizure was drawn up in a syringe and injected through her intravenous tubing. Fortunately, it had a rapid effect - the seizure stopped and she began to breathe on her own. However, now she was very drowsy, unconscious really. At this point the thought flew through my ind that if she vomited, it would probably be aspirated into her lungs and kill her. The only thing that would protect her lungs from stomach contents was inserting the endotracheal tube. I was not sure I could accomplish this easily in her. My back-up plan to sedate her lightly and have a look was no longer possible.

To make matters worse, her intravenous tubing had become dislodged during the seizure. She could not have the cesarean section without it. To start another IV in this patient was a challenge almost as great as the airway - and again my sole responsibility. The veins on her hand were impossible to see.

While the resident held the oxygen mask tightly on her, holding her jaw so that her tongue would not fall back, I searched frantically for another vein. I tried inserting the needle blindly to a spot where I knew a vein should be located. Blood returned back through the needle and I knew it was successful.

The obstetrician waited patiently and quietly, full of concern but asking me only to tell him when he could start. Thank God he was not the type to start yelling at the anesthesiologist and ask what was taking so long.

The baby's heart rate was measured and found to be slower than normal - a signal that she was not getting enough oxygen from the mother. If the baby was not delivered quickly by cesarean section, she may be brain-damaged.
I gave the mother the anesthetic medications into the intravenous tubing. The first one was to make her unconscious, the second to rapidly paralyse all her muscles and stop her from breathing on her own. These medications are necessary to get the endotracheal tube inserted without the patient coughing and possibly vomiting. I inserted the laryngoscope, hoping to find the familiar anatomical landmarks. She had bitten her tongue during the seizure so her mouth was full of blood. Nothing looked normal, but I managed to locate the vocal chords and insert the tube between them. I told the surgeon to go ahead. Within a couple of minutes, the team had delivered a small, drowsy but otherwise normal little girl. The baby was whisked off to the Neonatal Intensive Care Unit. After the surgery was finished I took my patient to the adult Intensive Care Unit (ICU), still sedated and unconscious. It would have been risky to awaken her and pull out the lifesaving endotracheal tube, since she could develop seizures again for up to 48 hours after delivery.

Two days later I went to visit her in the ICU. A few minutes earlier her baby had just arrived for the first visit with Mom. Her attention was naturally diverted. She said "I remember you - you're the doctor who gave me something for my headache." She remembered nothing about going to the Operating Room. She returned to examining every square inch of the new baby in her arms. The little girl, in turn, stared at her mother's face with the pure, unblinking gaze of the newborn.

Did her lack of appreciation of the role I had played bother me? No...and yes. No, because seeing the happy mother and newborn gave me a feeling of profound thankfulness that I had been able to do the right thing. My skill with intubation developed in just such life-threatening situations had stood me in good stead. Yes, because anesthesiologists seem fated to be cloaked in anonymity. As I took my unheralded leave, I reflected that, had I failed I would have had attention enough focused on me by the media and lawyers asking what went wrong and who was to blame. In the life of an anesthesiologist, no news is good news - a job well-done must be its own reward.

Pat Morley-Forster, MD, FRCPC
April 1998