Cancelling surgery: When the show can’t go on

It’s showtime.  No need to worry.  This is just another routine performance.  I can do this.  All I need to do is get on stage, do my dance, and wait for the curtain to fall.  Then move on to the next stage and do it all again.

The curtain opens.

My patient is wheeled into the operating room.  With the help of the circulating nurse, we guide her from the hospital gurney over to the operating room table.  With the grace and precision of a ballerina, I start my recital by securing an oxygen mask over her face.  Next, I apply the monitors – a blood pressure cuff to her right arm, a pulse oximeter probe to her left ring finger, an EKG sticker to each shoulder and one more on the left side of her rib cage.  Before turning my back on my patient to draw up narcotics, I start the Levaquin – one of two antibiotics she is to receive before surgical incision.  Less than ten seconds later, her right arm, the one with the IV, has a brilliant red streak tracking along the path of her vein.

The background orchestra stops abruptly.  The silence is deafening.

I’m forced to adapt.  Without a moment of delay, I disconnect the antibiotic from her IV tubing.  Quickly, I grab a vial of Benadryl from my drug cart.  Before I can draw the medication into a syringe, the patient speaks the words I never want to hear.

“I can’t breathe.”

I shoot the Benadryl into her intravenous line.  My hands are shaking, my adrenaline pumping.  I order the nurse to retrieve Pepcid, which will further help to diminish my patient’s escalating allergic reaction.  Meanwhile, I administer a hefty dose of steroids.  As fast as I am able to grab the next medication in my arsenal, her symptoms worsen.

“My throat is tight.  I feel like I can’t swallow.”

Mine, too – but for different reasons.

The scenery behind me changes to an ominous and foreboding backdrop.

I thrust an inhaler at the young woman.  While she puffs Albuterol, I grab my stethoscope.  Fortunately, she seems to be moving air well, and I don’t detect any wheezing.  But my patient has asthma, and I fear respiratory compromise is only moments away.

When I speak, my voice sounds high pitched and unfamiliar.

“Are you feeling any better?”

“No, but not any worse either.”

We sit there in the operating room for what feels like an eternity.  Every few minutes, I listen to her lungs.  Everything sounds normal, but she still feels like her throat is closing off.

The surgeon, the resident, the scrub tech, and the circulating nurse – they are all staring.  One minute at the patient, the next minute at me.

I am dancing on a stage of fire, where the critics are relentless.  One misstep, and I will be crucified.  It was not my choice to be here.  I never wished to perform.

Twenty minutes pass.  The patient remains stable.  I pull the surgeon aside and do my best to sound confident and convincing.

“I don’t think we should proceed with surgery,” I tell him.

“Why not?  What are you concerned about?  Not being able to intubate or not being able to extubate?” he asks.

“Yes,” I answer without hesitation.

The spotlight is on me, and the rest of the stage is pitch black. 

My skin burns under the scrutiny.  Even though I have rehearsed countless times, I am nervous and shaky.  I hate myself for getting so rattled.  I’m doing the right thing, but there are so many barriers.

The surgeon speaks, “Well, if you think it’s the right thing to do, then let’s cancel.  But Kate, what do you think we are going to achieve by delaying surgery?”

This act should have ended long ago, but the stagehands refuse to lower the velvet curtains.  I continue my pirouette, but I’m growing tired and my grace is fading.

“Well,” I say, “right now I have an asthmatic patient who may or may not go into severe bronchospasm at any minute.  By instrumenting her airway, I am likely to tip her in the direction of disaster.  This procedure is elective.  We have nothing to gain by proceeding.”

Finally, my performance ends.  From the galleys, there is unexpected applause in pockets of the audience.  Yet, other clusters remain silent, shaking their heads in dismay.

Tomorrow, the scene will be replayed, and the role of the anesthesiologist will be played by another.  My performance will be critiqued, ridiculed, and dissected.  Ultimately, those who never witnessed my performance will judge me.  The reviews, I am sure, will be unfavorable.  I should have kept dancing.

The show must go on – at any cost.

Kate O’Reilley is an anesthesiologist who blogs at katevsworld.

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  • http://twitter.com/ConsanoCMO Dr Scott Finkelstein

    As a fellow anesthesiologist in private practice, I understand the delicate balance you must strike when a case needs to be cancelled. There is tremendous pressure from the surgeon, from the hospital, and sometimes even from the patient themselves, to proceed with elective surgeries. Sometimes, as was clearly evident in your story about a patient having an anaphylactic reaction to antibiotics, the risks far outweigh the benefits of proceeding. I applaud your resolve and strong ability to advocate for your patient in an emergent situation. You clearly did the right thing, albeit much to the dismay of your surgeon. I’m not sure that everyone in our field would have performed that dance as gracefully.

  • Suzi Q 38

    Bravo.
    I would rather be inconvenienced than dead.

  • http://www.practicebalance.com/ PracticeBalance

    Your dance metaphor is spot-on, especially the part about being critiqued… One snapshot of your performance can get burned in the mind of a surgeon, or the mind of a patient or family, even though it may not be indicative of how things normally go for you in the OR. Such is the life of an anesthesiologist.

  • buzzkillerjsmith

    Doctor, You have nothing to gain by spilling your guts in a public forum while using your real name.

  • mark reinholtz

    steroids and fqs are contraindicated. Did fqs need to be used as a prophylactic drug in this case? There are far safer antibiotics with less risky side effect profiles that do not contribute to HAIs . Was the patient informed of the FQ risk and their ability to cause long term damage ?

  • Suzi Q 38

    I remember asking for a certain anesthesiologist on staff.
    He had excellent credentials and had been working at that hospital for at least 10 years.
    I remember that the staff could not promise me that doctor.
    I think that we should be able to pick our anesthesiologists just as we are able to choose our surgeons.

  • NA

    Too much drama!
    Here is how it really went in my opinion:
    She starts the antibiotic and she sees redness over the vein so she starts panicking and starts repeatedly asking the patient if she is having trouble breathing and if she is OK.
    This anxious behavior is usually contagious especially when the patient is another nervous woman, and sure enough the patient responds to the anesthesiologist’s hysteria by starting her own hysterical reaction, hyperventilating, and feeling that she can’t breath, although not wheezing and no change in her SPO2.
    At this point both the lady anesthesiologist and her patient are in fully blown panic attack.
    This is not an uncommon situation unfortunately in our business.

    • EmilyAnon

      “another nervous woman”

      (female) “anesthesiologist’s hysteria”

      (female patient’s) “hysterical reaction”

      “the lady anesthesiologist and her patient are in fully blown panic attack”

      Why was it necessary to pound away at the gender of doctor and patient during your criticism. And then add the catchall term “hysteria” , which historically indicated a female personailty disorder.

      • NA

        With all due respect the gender here was relevant.
        Extreme anxiety and panic attacks are more common in women.

  • ninguem

    Surgery is not “cancelled”.

    Surgery is “postponed”.

    The operation is necessary but not emergent. The patient comes back when the asthma is controlled.

  • David Savage

    I’m a surgeon and this is going to be very blunt. I apologize in advance for this. And I of course realize that I am seeing this from a surgeons point of view. But I have great respect for my anesthesia colleagues and NEVER start a procedure without first looking at them across the drapes and asking them if I may begin.

    I’m trying to look your scenario as objectively as possible… your patient had an anaphylactoid reaction, not an anaphalactic reaction. She didn’t crash (BP or Pulse Ox), you didn’t have to intubate her or give her vasopressors, and your actions (removing the instigating agent) were spot on. The reaction is not mediated by an Ig E response, so as soon as she was better… she was better. She didn’t have any lingering issues that would have interfered with a general anesthetic, and nothing that would have made her “more bronchospastic”. In fact, General Anesthesia is a EXCELLENT bronchodilator…(which is why we get them deep first and THEN intubate them… to avoid irritation from the ET tube. Propofol also works well as a bronchodilator. You identified the causative agent and knew that it wouldn’t be a future issue with the case…

    The patient was also in the SAFEST possible enironment… being attended to by an anestheseologist in an Operating Room, with a FULL complement of high tech equipment and a surgeon standing next to you…..it doesn’t get any better than that.

    I think I’ve got to side with the surgeon on this one. There seemed to be some unnecessary drama regarding this incident too… especially as you are describing it on this blog, in a public forum. YOU might have had nothing to gain by proceeding; but the patient, her surgeon, the hospital, the medical system in general would most likely have done better if you had proceeded. I’m wondering if maybe you should discuss this case with your more experienced medical colleagues instead of profesing your fear in a blog.

    Concern for patient safety is admirable and paramount;
    letting fear and anxiey get in the way of doing your job is not.

  • mark reinholtz

    the doc is right and savage is wrong. a reaction to an fq is unlike any other antibiotic . there is the initial reaction and the delayed side effects that come about from the reaction later. google fq reactions . and dr savage ORs are prob the most dangerous place to be in a city. far from the safest place as you describe.