(This) Sux

In November of 1993, thanks to the FDA, the package insert for Succinylcholine (or if you're British, Suxamethonium, or if you're most anesthesiologists and emergency physicians, just Sux) was changed. The new label stated that the drug was contraindicated in children and adolescents "except when used for emergency tracheal intubation or in instances where immediate securing of the airway is necessary."

This means if we give Sux to children, we had better have a darn good reason for doing so, like, "the kid's gonna die before my eyes unless I give it."

I gave it to a 5-year-old.

First day back after a vacation, first case of the morning at the "main" hospital my group serves.

I came in to set up my drugs and equipment in the morning as always - first a suction, laryngoscope, and machine check, then drug preparations. For children I whip out my little home-made table of specific doses, intravenous and intramuscular, for specific drugs by child's weight. I look at the weight that corresponds to my patient at that particular time and memorize the doses for the most crucial drugs. I draw up these "rescue" drugs before the case and place them in syringes that are always within my reach. Then I put a few bottles of candy scent in my pocket, go out and see the kids, and ask them which scent they'd like their "magic air" to smell like when it's time for them to breathe the magic air that will make them sleepy.

My little 5-year-old patient was going to have her tonsils out. She had little braids and a wiggly tooth. She had a little white sheep named Little Bear who had a little lamb.

Everything was going just like every other anesthetic for a tonsillectomy; she breathed her bubble-gum scented magic air, she went unconscious, my wonderful O.R. nurse was getting an IV, everything was going according to plan...

Then it happened. One moment I was giving her manual breaths through a mask snugly held to her face; the next moment, after a couple of coughs, she stopped breathing and I could not, try as I might, squeeze any more breaths into her little lungs. Her saturation dropped, 99%, 90%, 85%, 77%...in a matter of seconds it had plunged to terrifying. Mask ventilation was futile.

I asked my O.R. nurse to grab the Sux syringe next to me and push 2 milliliters of it into the IV she had just placed, and I asked a second nurse to call other anesthesiologists stat to the room for extra pairs of hands. Help arrived in a matter of seconds; by then I had an endotracheal tube in place and was ventilating the child again, and her saturation came back up rapidly to 100%. My colleagues, Maddog and Fred, drew up and gave one or two other protective drugs while my hands were full, saw that the kid was stable, patted me on the back, and took their leave.

It happened so fast. It took me maybe half a second to think, "Oh, crappe,* I need Sux" and another half-second to say, "Get that Sux and give 2 cc's of it now." But in that one second, if you were to project my thoughts on a screen slow-motion, I think you'd read something like this: This is laryngospasm. I can't believe this kid is actually laryngospazzing on me. Or could it be bronchospasm? No history of asthma...What else makes someone desaturate fast? Airway obstruction? So-called chest wall rigidity? Masseter spasm? But the IV's barely even in; we haven't given something that would cause that. Well, we're about to...Is that really the heart rate? Could be worse I guess, she's only bradycardic by five-year-old standards; if she were an adult she'd be fine. What if she goes into hyperkalemic cardiac arrest when I give the Sux? Or malignant hyperthermia...but how likely is that? She's more likely to stay desaturated (and croak) from no airway than to do all that...Still, I hope she doesn't have pseudocholinesterase deficiency, or an undiagnosed myopathy that would predispose her to cardiac arrest...Here goes...

As soon as the Sux went in, her entire body including her airway relaxed perceptibly under my hands and I was able to intubate her and secure her airway. All I can say is, thank goodness the FDA didn't outright ban this drug. It may be dangerous for a few in rare cases but when you need it, you need it badly.

She did beautifully the rest of the case. Then I was able to move on to the adult patient I had to intubated blindly because a plum-sized thyroglossal duct cyst was obscuring my view of the vocal cords...and after that I almost got the man whose every organ had something wrong with it (heart didn't work, pancreas didn't work, kidneys didn't work, lower esophageal sphincter didn't work, peripheral nerves didn't work, brain was kinda on-the-fritz too...), except my colleague George was on late-shift and wound up taking the case...

Somebody please tell me why I shouldn't quit my day job and move on to something that doesn't entail being responsible for other people's lives...

_____________________________________________________

*"Crappe," according to Wikipedia, is a Middle English word meaning " 'chaff, or grain that has been trodden underfoot in a barn' (c. 1440s), deriving ultimately from Late Latin crappa..." The other word, meaning excrement, is slang derived centuries later by Americans. I admit I actually was thinking the latter at the time, but I can't bring myself to use it in writing.

Scales

"Down the road someone is practising scales,
The notes like little fishes vanish with a wink of tails..."
from Sunday Morning by Louis MacNeice

I was astonished to read what Patty Mitchell wrote on June 7 at Oboeinsight, about how some of her colleagues don't require their students to practice scales because they don't believe scales are important. Perhaps I haven't earned the privilege of having an opinion about this, but surprise surprise, I do have one, just as I have one about times tables (they should be committed to memory at an early age), diagramming sentences (all school kids should participate in the exercise, lest a working knowledge of English grammar, seemingly a low priority in this country, be thrust into further decline), and learning poetry by heart (go ahead, call me old fashioned).

If I've learned anything from both dance and medicine, it's that expertise which requires physical activity also requires rigorous training. Repetitive physical acts in such endeavors are neither useless nor unimportant; they are, in fact, essential, both for the muscular strength and dexterity they develop and for the discipline they instill.

Two weeks ago I couldn't get past the first measure of Gabriel's Oboe by Ennio Morricone. Yesterday morning, facing a glorious day outside my bedroom window, I surprised myself by playing through eight measures -not well, of course, but considering I couldn't even try it not too long ago, I was glad just to be playing through the notes! I have no doubt that practicing scales - again, not necessarily well, but with good intentions, at least - has made a difference and added those seven new measures. I'm going to have to start working on F minor. I tried to figure out the adagio portion of the Grand Pas Hongrois in Raymonda, and those four flats aren't exactly second nature...yet.

But boy, I have no endurance. I have no wind control, no stamina in my hand muscles; my embouchure poops out after twenty minutes; I am an oboe wimp. And a "grace note" queen. Not a great combination! :)

***

Got called to the ICU today to manage yet another God-help-me type of intubation. The procedure went fine, and when one of the family practice docs started asking me about my approach, I found myself thinking back to residency, when we residents had achieved enough seniority to get sent to places like the ICU and the E.R. by ourselves, carrying a supply bag on our shoulders, all eyes watching as we attempted to do what others had already tried to do but were unable to. I thought back to my recent call to the E.R. at one of our smaller hospitals, a community hospital in the middle of a bunch of dairy farms, where after the E.R. physicians, I was the only other person around for miles who was qualified to even attempt intubating someone. All I can say is, thank goodness for those residency runs, which gave me chance to develop an approach. Thank goodness for scales.

Where does It come from?

I marvel at a gift my daughter has and that I, alas, do not: composing. She took up piano a little over a year ago. I heard her playing something so evocative after only two lessons that I poked my head out of the kitchen, where I was doing something completely ordinary like chopping vegetables, and asked her, "What's that you're playing?" The music reminded me a little bit of a procession for kings in a fairy tale or a bible story. Like something out of Menotti's Amahl and the Night Visitors, which we had recently seen and try to see every Christmas season.

"Oh, I'm just composing."

Composing! Wow, she was making that music up? How do people do that? Where does that music come from?

"It's wonderful, sweetie. Reminds me of Amahl."

"Yeah, actually, I'm calling it A Royal Appearance." That was her first composition. She was 8.

More recently she has composed a piece called At the Arcade, which sounds just like someone playing pinball or video games, and another called (at my suggestion), Stirring the Brew, a playfully spooky piece that sounds just like, guess what, someone stirring brew in a cauldron. She's also working on a musical, and the parts she has sung for me so far have blown me away.

Where does creativity come from?

One could spin an endless web of theories. In ancient Greece there were the nine Muses. Today the fashion is to attribute most things that involve human cognition to the function of little molecular messengers, the neurontransmitters. Some might add genes, spirit guides, environmental factors, God, faith, early childhood education, exposure to music, good nutrition, or any number of influences to explain people's gifts, and logically a combination of any of these factors might certainly contribute to human creativity. But it's like trying to explain how it is we hear certain combinations of sounds and call them "music," or why certain strains of music elicit tears or fears or longings. Ask my daughter where her music comes from, and she'll say, "It's been with me for months," or "I hear it in my head."

"Intuition" is similar. The day before my oral boards, at my husband's suggestion, I booked myself a massage. What better way to de-stress, right? There's a funny story about the whole spa experience that day that would take a whole other post to relate, but for purposes of what I'm thinking about right now, let me skip to the part where the massage therapist, seemingly out of nowhere, placed a hand right in the middle of a muscle in my lower back that couldn't have been more in need of a little un-kinking. I was shocked at the sure-fire accuracy of the maneuver and asked, "Wow, how did you know that?"

The laconic, Italian-accented reply: "Experience."

And I've said the same thing. At one of the hospitals my anesthesia group serves, we teach EMTs and paramedic students about intubation. When they really can't see the vocal cords or can't place the breathing tube in the trachea, I quickly step in and complete the procedure, and often I'm asked, "How did you know how to adjust that so you could get it in?" The answer truly is experience. I always tell the paramedic students it took me HUNDREDS of airways (as in, intubating 3-4 times a day for 2-3 months) to feel really comfortable with the "straightforward" ones, and hundreds more to feel I had the ability to tackle a challenging one.

Once in the ICU during my residency the surgeon in charge watched me do one of those God-help-me intubations, and while I was doing it he asked, "Can you see anything?" The answer was no, but I asked him to hand me the tube anyway. It went in. "Lucky," he said. Maybe, but the more I learn and the more experience I have, the luckier I seem to be. Yet never "lucky" to feel smug about intubating people. If I've learned anything in my line of work, it's respect for the airway!

Just last week at one of the other hospitals we serve, the E.R. doc had a really tough time with the airway, had tried for a while to secure it, but then sent someone to the O.R. to ask me to come and take a look (another long story that would take a separate post to relate). I looked. It was tough. Darn tough. I could easily have missed. But something told me to bend the tube a certain way, and wiggle the laryngoscope just so, and thankfully the tube went in. But no amount of success, at least for me, will make these "scary" airways less caution-worthy. Difficult airways just can't be taken lightly, ever. My heart still quickens a little every time, and I still say a split-second mental prayer over them to help focus my efforts.

But this is all stuff that involves training, learned skills, and practice. Granted, creative acts take work and practice too, but with those, there's that inexplicable element, the mysterious "place" that works of art (and life) come from. How did Ralph Vaughan Williams come up with his Concerto for Oboe and Strings? How did Harper Lee's vision of Calpurnia or Jem come to life so vividly on the page?

Sure, neurotransmitters are important. I've seen and heard of enough anecdotes about people "losing" their creativity when they take certain neurotransmitter-altering drugs. One writer I read recently also describes the opposite - a medication that seemed to give her hypergraphia, a need to write often and copiously (and no, despite what the entries in this blog might suggest, I am not taking the aforementioned medication, unless it's at all similar to any compounds found in chocolate!). So yes, the brain matters. (And just as an aside, I think people should be less critical of the use of some of the medications I've alluded to here. You wouldn't tell diabetics to just "get over" their pancreas problem if they need medication. If people with neurotransmitter issues need medication as well, and have the guidance of experts to help select those medications, they should take the meds they need, and/or practice yoga to boost their levels of GABA, etc.) Clearly, neurotransmitters are powerful agents for human ability, behavior, emotion, health. etc. But are they the whole story?

When I think of my children's faces, my daughter's pieces, places I love, stories I want to write, I have a hard time imagining how those thoughts could simply be stored and recalled, repeatedly, by neurons and their neurotransmitters. I think there's more to thought than we think.

***

Had my 5th oboe lesson today. Lots of fun. We laughed over how "I hate half holes!" Went over C, F, & G major scales as planned, and a couple of others, E flat and A major. I have my work cut out for me but I'm excited to get into some "real" music-work. Started to work on dynamics too for the first time - and again, that feeling of "where did that come from" arose when I hit a note more piano by accident after trying several times.

Kyoko asked, "What did you do just then?"

"I don't know, I don't know! What did I do? I have no idea why that worked!"

But just like intubation, playing repeatedly gives you an idea, maybe one that you can't verbalize readily, but it's certainly there. A "gut feeling" about how to move your muscles to produce an effect. I hope as I practice and play more, I'll have more of that inexplicable "instinct" about what adjustments to make. Dance was like this too. After a while, with lots of training, lots of practice, lots of work, I needed less thought to do what I wanted to do. Less thought, more...what? Very mysterious, all this brain / spirit / creativity stuff.