Monique

Meet Monique

Monique is a 40-year-old schoolteacher who has suffered from heavy painful periods for the last few years and has  fibroids of the uterus. She has wanted to have a  hysterectomy but her doctor has advised her against having this done. Now, however, Monique’s last Pap test shows a few irregularities. Since receiving these new results, Monique and her doctor have discussed the various treatment options. Monique also read widely on the subject and has decided that she will have the hysterectomy.

“I’m not at all worried about the operation – it’s something I’ve wanted to have for a while. But I am really worried about the anaesthetic. My mother’s aunt died during an operation – they said she couldn’t take the anaesthetic. In fact, we always talk about it whenever there’s an operation on TV.”

At the hospital

Monique’s operation is to be performed mid-afternoon and she is advised to be at the hospital by mid-day. She had received a letter from the hospital a week earlier with instructions as to what clothes, etc., she should bring, where to report. The letter also outlined what she should and should not eat and drink on the day before, and on the day of the operation.

Monique is met by the ward nurse, who escorts her to her room. Having taken Monique’s blood pressure, pulse and temperature, the nurse asks Monique to step onto some scales.

Embarrassed, Monique exclaims, “I seem to have put on a few pounds since the fibroids were diagnosed – I’m not usually that weight. Does everyone have to go through this?”

“Yes,” says the nurse. “We need to know your weight because the doses of all the drugs and medications are adjusted to that. Your anaesthetist in particular will want to know exactly what you weigh.”

“When will I meet the anaesthetist? That’s what I’m really worried about.”

“According to the Operating Room schedule, it’s Dr. Wong today, and he always comes around about an hour before surgery. So he should be here soon.”

About ten minutes later, Dr. Wong appears and introduces himself to Monique and her husband, Charles.

“Hello, I’m Raymond Wong, your anaesthetist, and I’ll be looking after you today while Dr. Reitz does the operation. You’re having a hysterectomy, is that correct?”

“Yes, and I’m more worried about the anaesthetic than the operation,” says Monique.

“Well, it’s my job to make sure that you don’t need to worry – either of you. I’m there to look after you during the whole time you are in surgery. Have you had any anaesthetics before?”

“No, this is the first time.”

“Have there been any family problems with anaesthetics?”

“Yes, my mother’s aunt, my great-aunt, died during an operation – they said she couldn’t take the anaesthetic. The family always talk about it whenever there’s an operation on TV.”

“Perhaps we can sort out what happened? Do you know much about it – was she old, young, was she sick?”

“The only thing I know is that it was a long time ago, before I was born, and I guess she must have been in her 50s or 60s. Apparently she just didn’t wake up afterwards.”

“Do you know what operation she was having?”

“No, I’m not sure – my mother would know but she’s away at the moment, visiting my brother out in the country.”

“Has your mother had any anaesthetics?”

“Oh yes, she’s had quite a few and they don’t seem to worry her. She bounces back and now she’s fit as a fiddle.”

“What operations has she had?”

“Let’s see. There was the bowel obstruction. I think she’d had her appendix out when she was a little girl. Then she had to have a  colostomy and then they fixed that up. But she’s really good for her age – hope I’m the same when I’m her age.”

“Well, the problem with your great-aunt doesn’t sound like anything hereditary then, and certainly the chances of not waking up were much greater with anaesthetics fifty or so years ago, than they are now. I’ll keep that information in mind during your anaesthetic and recovery, but unless there’s some other specific information, I think we can fairly safely ignore your great-aunt. And you’ve been perfectly well otherwise – no colds or ‘flu recently?”

“I had a bout of the ‘flu – maybe it was just a bad cold – a couple of weeks ago, but that’s all cleared up.”

“OK. Now are you taking any tablets or medicines?”

“Only the Pill.”

“Right, and which one is it – one of the low-dose ones?”

“I’m not sure. Charles, can you get the packet out of my bag?”

Dr. Wong checks the  oral contraceptive and determines that it is indeed a low-dose type. He makes another note on the  chart in which he has been jotting throughout the interview.

“Now, I’ll need to examine you a bit – have a listen to your heart and lungs, and look at your mouth – what we anaesthetists call the  airway. And you are right-handed, yes?”

Monique nods in agreement.

Dr. Wong first takes Monique’s hand, feels her pulse, and then runs an index finger over one of the veins on the back of Monique’s left hand.

“Now, to start the anaesthetic, I’ll be putting in an  intravenous or drip, you know, a little plastic needle into this vein on the back of your hand here.”

“Won’t that hurt?” asks Monique worriedly.

“No, because we’ve got enough time for the nurse to put some local anaesthetic cream on, as soon as I’ve finished examining you. That cream will make it numb, so you should only notice some slight pressure as I slide the needle in.”

Dr. Wong looks at Monique’s jaw and asks her to open her mouth, and then to stick out her tongue. He has noticed while speaking with her that she has prominent front teeth and a slightly receding lower jaw. He looks in at the roof of her mouth ( palate) and observes that it is narrow and that her two front upper teeth slightly overlap each other. He then has her protrude her lower jaw to see if she can move her lower teeth in front of her upper teeth. She is barely able to do so. After asking Monique to relax her jaw, he places two fingers of his right hand under Monique’s jaw.

“What are you doing?” Monique asks.

“I’m measuring the distance from the edge of your lower jaw to the top of the  thyroid cartilage or Adam’s apple here in your neck. What I’ve been doing is what we anaesthetists call ‘assessing the airway’ – checking how wide your mouth and throat are and determining whether or not we might have any trouble inserting a breathing tube in through your mouth and down into your windpipe or  trachea. I need to do that as part of the anaesthetic – to take over your breathing and ensure that the passage for oxygen is clear. That won’t be done until you’re unconscious, so you won’t know the tube is going in, and it should be out by the time you’re fully conscious again.”

“How do you get the tube in?” asks Charles, who until now has not asked or said anything.

“I’ll be using a special instrument called a  laryngoscope. It’s really like a big tongue depressor with a special light attached, so that I can see where to place the tube.” Dr. Wong turns to Monique and continues. “The laryngoscope goes into your mouth once you’re unconscious and I use it to hold your tongue to the left in your mouth and also to pull your lower jaw forward. Just as I had you do now, when you moved your lower teeth in front of your upper teeth.”

“Is that what causes the sore throat afterwards? My girlfriend had the same operation about two years ago and she said the worst of it was the sore throat. Does the tube itself do any damage?”

“Well, you’ve really asked two questions. First, getting the tube in does put some pressure on the tissues inside your throat and I think that’s what causes the sore throat. In some patients it’s necessary to pull the jaw forward more strongly than in others, so there’s a bit more pressure on the soft tissues in there. In your case, your lower jaw barely moves forward of your upper jaw, and the distance I measured under your chin looks a little less than normal, so I may have to have to pull a little hard. But I don’t anticipate any major problems. As for the tube itself, you might be a little hoarse for a day, but it shouldn’t be any worse than that.”

Dr. Wong then asks, “Have you had any special dental work done?”

“I had a chip fixed on one of these front teeth.” She gets out a mirror from her purse and says, “Yes, the left front one. Otherwise they’re all mine, not even a filling!”

“I’ll need to watch that,” replies Dr. Wong. “There’s always a slight chance of damage to teeth, and veneers or bridges are less strong than most natural teeth, although there’s also a risk with brittle or previously chipped teeth. I’ll be doing my best to avoid any pressure on your teeth, but I should just let you know. I’ve drawn a little picture of exactly which tooth has the veneer, so not only will I know, but also the nurses who look after you in the  recovery room.”

“Thanks! I need these. I do a bit of amateur theatre and people say what a perfect smile I have.”

“I’d like to examine your chest. Would you like your husband to stay or to go out?”

“I’m perfectly happy for him to stay, if it’s all right with you.”

“Yes, thank you. Now, if you could just remove your dressing gown so that I can listen to the back of your chest.”

Dr. Wong uses his stethoscope to listen to Monique’s lungs, and then slips the stethoscope around the front of her chest, listening to her heart.

“Fine, all clear.”

“Do you have the results of my blood tests that I had last week? I think I had something called a cross-match.”

“All your test results are normal. And as for your cross-match, you’re A positive.”

“Does that mean I’ll be given a blood transfusion?”

“You will lose some blood during the operation, although probably not very much, so it’s very unlikely that you will be given blood. But our surgeon likes to have some compatible transfuse patients unless they really need it.”

Dr. Wong continues, “I do need to explain a couple of other things. Because you are having a hysterectomy, you have an increased likelihood of a blood clot or  deep vein thrombosis (DVT) in the legs. This is because you are on the Pill. We’ll be giving you a couple of doses of a drug called heparin to thin your blood and also have you wear some fancy stockings. Both of these things should help to avoid any clots. In addition, the sooner you get up and walk about after the operation, the better.”

“I’ll certainly try to do that.”

“We also need to plan your recovery, especially as far as pain relief goes. This operation can be very painful afterwards. You’re going to have a big cut in your tummy. There are a couple of ways that we can provide pain relief. One is with injections into your bottom. Another is with injections through the intravenous line, which you control by pushing a special button whenever you want some more drug. Many patients like this technique, because they get a dose whenever they need it, rather than whenever the nurse is able to get to them. That’s why we call it patient-controlled analgesia or PCA. And there’s very little chance of having too much drug, or an overdose, as the pump has a computer that is programmed to give a specific dose and no more. It’s a bit like a automatic teller (ATM) you can’t take out a thousand dollars every five minutes. Same thing with this pump. The third option for pain relief is with a little tube placed in the middle of your back – an  epidural. We can give you small amounts of local anaesthetic and painkiller, like  morphine.”

“Like I had for our first baby. It worked very well, but I was never really happy and I only needed the gas for our second. But, I think might have had an injection as well. I just don’t like the idea of having a needle in my back. If I had a choice, then I’d rather have the pump.”

The anaesthetic

Later that day, Dr Wong greets Monique in the Operating Suite waiting room. She has walked there with Charles and a nurse and has already had her injection of subcutaneous heparin to help reduce blood clots forming in the veins of her legs.

“Hi! How are you feeling, Monique?”

“A bit nervous, I can tell you,” Monique replies, holding Charles’s hand tightly.

“If you want to say your good-byes, I’m all ready to go. We’ll walk to the Operating Room. When you’re ready…”

They enter the Operating Room together and Monique is amazed by the number of people there. She immediately recognises her surgeon who is talking to a colleague. He comes over to her.

“Hello, Monique. All ready for the big day? Can I introduce my assistant surgeon, Dr. Carpenter? She’s going to help out. I’ll leave you in Dr. Wong’s care now, and I’ll see you and Charles later.”

There are two nurses, already in sterile gowns and gloves, setting out a huge array of shining metal objects. They look up from their work as Dr. Wong asks Monique to climb onto the operating table. He introduces the  anaesthetic technician, Ben, who steadies Monique as she steps onto a stool and then turns and lies down on the table. Ben places a pillow under her head as she does so and then covers her with a blanket. It feels nice and warm, as if it has been in a heater.

Dr. Wong attaches a  pulse oximeter probe on her left index finger while Ben fits a blood pressure cuff to her right arm. She feels the cuff suddenly get tight and then gradually release. Some beeping appears on the machine near her head. She is conscious of a large object and some flashing lights. Ben attaches three sticky pads with wires connected, one to each of her shoulders and one to her left hip.

“Just attaching you to the electrocardiogram  monitor,” says Ben, “so we can watch your heart rhythm.”

Monique looks up at the huge light suspended above the operating table and wonders how bright it must be when turned on.

“Now, first the intravenous,” says Dr. Wong as Ben takes Monique’s left arm and places a tourniquet around it just above the elbow.

“There’ll be just a little jab – a bit like the one you already had for the heparin.”

Monique winces a little as Dr. Wong injects a tiny amount of local anaesthetic into the skin on her forearm. He then takes a much larger needle and  cannula and places it into a vein. Ben releases the tourniquet and connects the intravenous line, allowing some of the fluid to flow into Monique’s vein.

“Still OK there?” asks Dr. Wong.

“Yes, still here,” says Monique, who manages a faint smile.

“Right, everything ready, Ben?”

Ben nods.

“Now Monique, I’m going to inject some drugs through the intravenous line. You’ll feel cold going up your arm and then perhaps a funny taste in your mouth. The next thing you’ll know, the operation will be all over. You can count if you like.”

“One…two…three…” Monique slips into unconsciousness as she reaches ten.

Dr. Wong gently lifts her chin up, allowing her to breathe without snoring and places a mask over her nose and mouth. As she stops breathing, he takes over, squeezing the bag attached to the  circuit and inflating her lungs with oxygen. He then turns on the nitrous oxide and a small amount of isoflurane. About two minutes later, he turns off the nitrous oxide and isoflurane and removes the mask from Monique’s face. With the gloved fingers of his right hand, he opens her mouth and then, using his left hand, inserts the metal laryngoscope into the back of her throat. He pulls up on the ‘scope, being careful not to touch Monique’s top front teeth with it. He peers into the back of her throat.

“Looks as if I might need the introducer,” he murmurs to Ben. “Can only see the tip of the  epiglottis.”

Dr. Wong removes the ‘scope, turns the nitrous oxide and isoflurane back on, and replaces the mask over Monique’s face. He continues to ventilate her as he waits for Ben to insert the special length of flexible wire into the breathing tube. Ben then proceeds to curve the end of the tube into the shape of a hockey stick. He holds it up for Dr. Wong to see.

“OK?”

“Great, thanks. Now let’s have a go.”

Dr. Wong proceeds to reintroduce the ‘scope and pulls hard on it, so that Monique’s head is lifted slightly from the pillow. He takes the tube in his right hand and inserts it into Monique’s  larynx and down into her trachea.

“In.”

He removes the ‘scope carefully, continuing to hold the tube with his right hand. Ben removes the introducer and connects the tube to the circuit from which he has detached the mask. They both turn to look at the carbon dioxide monitor. Satisfied that the tube is indeed in the trachea, Dr. Wong hits the button on the automatic blood pressure machine and proceeds to inject some more  narcotic into the intravenous line.

“Think you could start,” he says to the surgeon, who has been waiting patiently.

“No rush,” replies the surgeon. “Wouldn’t want there to be any problems.”

“Couldn’t agree more, but she’s going to have a sore throat postop.”

After the anaesthetic

The operation successfully completed, Monique has been back on the ward for about three hours. She is feeling a little nauseated. Her  incision is reasonably comfortable and she has been using the Patient-Controlled Analgesia (PCA) as needed.

“It’s not as bad as I thought. The PCA certainly controls most of the pain and I’m able to sleep. In fact, I keep drifting off. But I’ve thrown up a couple of times in the last hour and that hurt a bit.”

Dr. Wong gave Monique an  anti-emetic during the anaesthetic. However, it doesn’t seem to have been fully effective.

“And my throat is quite sore. I think I should stop talking.”

An hour later, after consulting with Dr. Wong over the phone, the nurse injects a different anti-emetic into Monique’s intravenous line.

Soon Monique is feeling much more comfortable as the nausea fades away. She drifts off again into a light sleep.