Toes

"When the toes wiggle, the patient is completely paralyzed." I knew what the anesthesiologist was saying of course. We were administering a nerve blocking agent, and as it travels down the body, muscles spasm slightly before they are paralyzed. The agent blocks the nerve impulses from getting to the muscles by binding to the receptor site, and as the drug binds to the sites it causes the muscle to spasm and then relax. Its like a wave of muscular contractions traveling through the body,  like some kind of strange, medically induced orgasm. The patient has no memory of this of course, because we sedated her before administering the ‘sux’ or succinylcholine. So when they paralyze a patient for an operation, the gas passers always look for that toe wiggle.

I am observing a relatively rare operation, a bullectomy, on one of my patients. Mary is 56 yrs old with severe emphysema, COPD, and has been on a ventilator for seven months, unable to be weaned. Inside her lungs are large air filled bubbles or bullae, a byproduct of her COPD, and the swollen bullae are compressing what is left of her normal lung tissue. Her only hope of ever getting off the ventilator is the operation, but because her lungs are so compromised there is only about a 4 in 10 chance she will survive the attempt.

The surgeon makes the incisions and passes the fiber-optic scope into her chest as we all watch on the TV screen. We see inside her chest now, the diseased areas showing plainly. We watch the valiant attempt by the skilled surgeon to remove the largest bullae, and we all sigh as we see the extent of it. There is so little normal tissue left.

"Oxygen saturation dropping," says the anesthesiologist, "85,  … 80… 76." Normal sats are 96 – 100, and heart problems often occur as the sats dip below 85. We have to give drugs to stabilize the heart rhythm. The sat stabilizes out at 66, then slowly rises again to 86 and stays there despite all the techniques we use to further raise her 02 levels.  She is on the razor’s edge.

I wonder if she will wake up.  Her heart is still beating in the recovery room, and I am with her  because If she awakens, I want her to see a familiar face. I try several times to rouse her with no response, so I wait. I try again and her eyes open slowly. I don’t know if she is mentally aware or opened her eyes only because I stimulated her. She shows no sign of recognition.

"Mary the procedure is over and you are in the recovery room. Do you understand?" No obvious response. "Mary, can you squeeze my hand?" No response. "Mary," I speak louder now, "Can you wiggle your toes?" And there it is, toes moving slowly. I look at her face again and her eyes are now focused on mine.