Tales From VA Anesthesiology

There we were in New Caledonia. All our supplies went out to replace what sank on [USS] Coolidge, including a lot of food. Well, there were deer on the island. So we took out a truck and a rifle and wouldn’t you know we came upon a roadblock in the form of a big steer. We figured it looked enough like a deer. My buddy shot it dead with one shot. We dressed it and loaded it into the jeep. Hardly before we even got back to the mess hall, the officers’ cook came sniffing around. He and our captain agreed it was easily the biggest deer they’d ever seen and appropriated it to the officers’ mess. Next day the CO [commanding officer] of the whole outfit came by and announced it was the best tasting ‘venison’ he’d ever had. I heard the farmer got paid a pretty penny for that steer. I didn’t get a damn bite.

He delivered this last bit with relish.

When the conversation returned to anesthesia, I read them the record of his hip fracture repair. I explained that on the face of it, the report seemed uneventful. One daughter asked astute questions about his awareness. I explained that although awareness during general anesthesia is possible, it seemed from the record, he’d had plenty of anesthesia during the case and that there is always less at the beginning and end, the periods that apparently had caused him distress. I also explained that most studies report the incidence of true awareness as at most 1 out of thousands of events and that he had none of the established risk factors for it, such as female gender, young age, chronic substance abuse, cardiac and obstetric surgery, and history of awareness.¹

The other daughter wondered why he was so agitated afterward. I recited data on the frequency of postoperative delirium in elderly patients but explained that the range is wide, depending on the study and population, from about 1% in elderly patients undergoing ambulatory surgery to 65% for open aortic surgery.^2,3 I added that their father had 2 of the strongest risk factors for delirium, advanced age and cognitive impairment.³ Only after airing each question about the hip surgery in detail were they ready to discuss the eye surgery.

He started that conversation with the right question: “Do I really need it?”

I quoted my surgical colleague’s concern. I told him that, should he opt to undergo the surgery, I was confident that this time around his experience would be different from the last.

“If you’re okay with it, all you need is some numbing medicine from the surgeon; you won’t need any anesthesia from me.”

I walked step-by-step through what they could expect on the day of surgery. Maintaining control was of obvious importance to him. He felt comfortable going forward. His daughters intuited that less would be more for a quick recovery.

We then addressed the DNR directive. I acknowledged his absolute right to self-determination and explained that the need for resuscitation is, at times, a consequence of the surgery and anesthesia. I reassured them that our plan made resuscitation and intubation highly unlikely. They also asked to use any interventions necessary to restart his heart if it should stop beating. I documented their decision in my notes and communicated it to the surgical team. We had talked for 90 minutes.

I met the patient and his daughters on the day of surgery in the preoperative holding area. I inserted an IV, applied electrocardiography leads, and affixed a pulse oximeter and a noninvasive blood pressure cuff. In the operating room (OR) we took time to place his 99-year-old joints into, as he said, the “least worst” position. He tolerated the injection of the local by the surgeon perfectly well. We were in the OR for 3 hours, during which he taught me a fair amount about boating and outboard engines among other things. Pathology reported clean margins. He was discharged home soon after and had an uneventful recovery.