The Patient Was…

The patient was an eighty-year-old woman with severe peripheral vascular disease. The term generally refers to narrowing and blockages in blood vessels outside of the heart, such as in the legs or even in the blood vessels carrying blood to the brain. Vascular disease inside the heart is usually referred to as coronary artery disease or coronary heart disease.

The arteries in the patient’s legs were severely stenotic (narrowed in layman’s terms) and there were multiple blockages. The obstructions to blood flow meant that the tissues of her legs, especially the muscles and nerves, did not receive adequate amounts of oxygen-carrying blood. Although she had no symptoms at rest, any attempt at activity, even walking, caused disabling pain. Her lifestyle, normally active, was consequently severely limited.  

Fortunately, the blockages in her legs were in relatively large arteries that could be treated surgically, allowing for more blood to perfuse the tissues. The smaller blood vessels in her legs were fairly clear of disease; this meant that  increased flow through the larger arteries, if surgery were successful in clearing or bypassing the blockages, could be handled by the smaller vessels and blood could reach the oxygen-starved tissues.

The patient herself was very bright, and well-informed and opinionated on many subjects. Much of the time during her regular visits to my office was spent in friendly argument and debate in any number of areas. Frankly, I enjoyed the intellectual stimulation. As expected, she prepared herself as well as possible for discussions of her medical condition and available treatments.

At the time she was my patient, endovascular treatments  —  minimally invasive procedures done inside blood vessels through small incisions  —  were not approved or available for peripheral artery disease. And medications were ineffective in patients with severe blockages in their blood vessels. Today, while medications still have somewhat limited benefits, endovascular surgery treatments are widely used for blockages in blood vessels, and results in many circumstances rival or even exceed those of standard surgery.

The patient’s reading and other information-gathering activities had led her to understand that the risks of surgery itself  —  surgical injury to her legs causing further damage   —  was small, although not negligible. A larger and more important danger, and one considered more serious to her, was the risk of anesthesia.

The patient was not wrong. General anesthesia can have profound effects on many body organs and systems. The most serious of these effects relate to the brain. Short-term problems include post-operative confusion, and nausea and vomiting due to the effects of anesthetic drugs on brain tissues. While these may be troubling enough, it is the long-term cognitive effects on brain function that people fear most. And every possible adverse effect of anesthesia is worse in elderly patients.

The patient was extremely concerned   —  and rightly so  —  about the possibility of long-term brain dysfunction due to anesthesia. Her fear, while perhaps somewhat exaggerated, was nonetheless real, and represented an impediment to proceeding to fix the serious circulatory problem affecting her life. She reasoned, correctly, that the less time spent under anesthesia the less likely was any brain damage from the drugs. Reduced exposure time meant reduced damage:  The equation was clear.

Duration of surgery became a focal point of her decision about undergoing the proposed operation. How fast could it be done? Could anything somehow shorten the procedure time? Could ANYONE somehow do it faster than anybody else?

Now, one of the top vascular surgeons at our hospital was extraordinarily deft in the operating room. He enjoyed a reputation not only as an excellent surgeon, but a fast one. He had operated on patients of mine, and in some instances I had chosen him for his speed as well as his general skill. I told the patient about him and she was intrigued.

Jokingly, she asked, “So, if he was in a shootout at the OK Corral, would he draw faster than anybody else?”

Sticking to the script, I said, “If he were a gunslinger, he would be the fastest gun in the west.”

I arranged a consultation with the surgeon, and the operation was scheduled. At the patient’s request, I agreed to be in the hospital and immediately available on call during her surgery in case of a problem, something I did for other patients at high risk or with unusual concerns.

 I saw the patient on the morning of surgery, shortly before she was taken to the operating room. She was apprehensive, but normally so, and expressed specifically how pleased she was that she was going to be operated on by the fastest surgeon.

A very short time after she had gone to the operating room, I was paged by the overhead paging system and instructed to go to the patient’s hospital room. It made no sense, because she should have still been in the OR. When I got to her room, she was wide awake, sitting up in bed.

“You said he was fast,” she said, smiling, “but I never expected this! I’m already done.”

I didn’t know what to say, or what had transpired, so I stepped out for a moment and called the OR. What had happened was that just as the patient went under anesthesia, the surgeon approached the operating table, suddenly doubled over groaning, and collapsed on the operating floor. An emergency was called, the surgeon was taken to the Emergency Room where acute gastroenteritis (inflammation of the upper and lower intestinal tracts) was diagnosed. He received fluids, antibiotics and was later fine.

Of course, the operation was cancelled because no incision had been made; the patient had received only a minimum of anesthesia and was awakened easily and quickly with no residual effects. She was returned to her room, but nobody told her what had happened.

I returned to her room, but before I could explain the circumstances of her aborted surgery, she launched into praise for the surgeon. “You said he was fast, but this is ridiculous.”

“Look,” I said, pointing to her upper thigh where the main incision was to have been made, to show her nothing had been done.

“Oh, my God,” said exclaimed. “He didn’t even leave a scar! What a amazing surgeon he is. Thank you for choosing him for me.”

I grabbed her hands, looked directly into her face, and said, “Listen to me. The doctor got sick. He was taken to the Emergency Department. He didn’t operate on you. Nothing was done to you. You didn’t have an operation.”

We went back and forth a few more times. She couldn’t conceive that she had been to the OR, been anesthetized, and then  —  nothing! She was so sure she had had surgery by the “fastest gun in the west.”  Finally, she got it. The disappointment was profound.

We persuaded her to accept the explanation and, reluctantly, she agreed to undergo the operation again. It went uneventfully, but she was a bit unhappy. After all, although her time in the OR was short, it wasn’t so brief as the first time. And she did have a scar.