Rackling against the breast bone

When I was a kid, I liked to do drugs as much as the next trailer trash, but I never, never understood how someone could stick a needle in their arm–until I had my wisdom teeth out. (Trailer trash explained in the English notes below.) The oral surgeon pushed the plunger on the syringe, I watched the medication travel down the IV line, and before I slipped off into unconsciousness, I heard the sound of the wind blowing in my ears and thought Ohhhhhhhh–THIS is why they do it.

I was lucky–before anesthesia was invented in the mid-19th century, that would’ve been a horrible procedure. Here’s a woman’s description of her mastectomy in 1811. Her name is Fanny Burney, and her record of the operation has survived until today because she was both a popular novelist and a part of the court of George III. This extract from a letter to her big sister Esther is quite unusual, in that it is a rare record of pre-anesthesia surgery from the patient’s point of view, rather than from the surgeon’s point of view, which is much better documented. Just in case you don’t feel up to reading the whole dreadful thing, I’ve shortened it, and then I’ve bolded the most horrific sentence—the sentence that people cite the most.  You’ll find the whole thing at the bottom of the post, after the English notes.

…when the dreadful steel was plunged into the breast—cutting through veins—arteries—flesh—nerves… I began a scream that lasted unintermittingly during the whole time of the incision—and I almost marvel that it rings not in my Ears still! so excruciating was the agony. When the wound was made, and the instrument was withdrawn, the pain seemed undiminished, for the air that suddenly rushed into those delicate parts felt like a mass of minute but sharp and forked poniards, that were tearing the edges of the wound—but when again I felt the instrument—describing a curve—cutting against the grain, if I may so say, while the flesh resisted in a manner so forcible as to oppose and tire the hand of the operator, who was forced to change from the right to the left—then, indeed, I thought I must have expired… The instrument this second time withdrawn, I concluded the operation over—Oh no! —Dr Larry rested but his own hand, and—Oh Heaven!—I then felt the Knife rackling against the breast bone—scraping it!—This performed, while I yet remained in utterly speechless torture…

Once a year I spend a week in Guatemala with a group of physicians, nurses, operating room techs, and therapists who do free surgeries for people for whom the almost-free national health care system is still too expensive.  When people think about groups like ours, they mostly think about the surgeons, and the stories that people want to hear are mostly about the surgeries that those surgeons do—the children who will be able to get married some day because a plastic surgeon repaired their cleft lip; the child who will be able to learn to write because the hand surgeon gave him functioning fingers; the woman who will be able to go to the market and sell corn again—thereby getting cash to pay for her kids’ school supplies—because the gynecological surgeons repaired her prolapsed uterus and urinary incontinence. There’s someone who usually gets left out of these stories, though–the anesthesiologists and nurse anesthetists who made it possible for those surgeries to happen.

Reasonable people could debate about what the most important inventions in the history of humankind have been. The wheel makes most lists; penicillin gets on a lot of them; stupid ones have “The Internet.” Here’s my hypothesis, in no particular order:

1. The toothbrush
2. Vaccines
3. Corrective lenses
4. Anesthesia

After that, the importance levels drop off pretty quickly–vaccines have killed some diseases forever (and may kill more if bad hombres with political motivations don’t prevent it–Boko Haram, Trump administration Cabinet member Ben Carson, and occasional presidential candidate Jill Stein come to mind here). Penicillin, on the other hand, is a once-great idea whose time will soon be past, leaving us with no good answers for XDR (extensively drug-resistant) tuberculosis or for people like my former Navy shipmate whose penchant for returning from port visits with gonococcal pharyngitis was legendary throughout the 6th Fleet. Few things will ever be as near and dear to our hearts as our toothbrushes, but the Internet will die as soon as the zombie apocalypse starts, leaving us poorer in idiotic Twitter feeds (see death of Internet) but immeasurably richer in our appreciation for the value of our ties to our fellow humans (see zombie apocalypse).

Anesthesia, though: let’s think about some things that would not have ever happened without anesthesia. Bear in mind that before anesthesia as we know it today was invented in the 1840s or so, surgery was something to be avoided at all costs and, in the case of non-emergencies like cancer, until the last possible minute; if unavoidable, it was to be done as quickly as possible. (The main criterion for the quality of an amputation, other than the patient surviving it, was how quickly it was done; as far as I know, amputation was the main surgical intervention of the American Civil War.) With anesthesia, though–with anesthesia, surgeons could be careful. They could do things that took time; they could do things that were complicated. As Dr. David Metro, our chief anesthesiologist, put it to me: “anesthesia is what has made every surgical advance since the mid-19th century possible. Organ transplantation–it saved over 33,000 lives last year–cochlear implants, cataract surgery, hip replacements, coronary artery bypass surgery–all of that is only possible because we can put patients to sleep, keep them there painlessly for as long as necessary, and then wake them up again afterwards.”

That’s what anesthesia has done for us–but, on some level, anesthesia is just a bunch of chemicals. You could give them to yourself, like folks once used ether for fun. (See John Irving’s novel The cider house rules for where playing with ether can lead–it’s nowhere good.)  But, anesthesiologists–they’re another thing altogether. I’m not talking here about their technical skills–about the nurse anesthetist who worked the night shift in a hospital where I worked in the late 1980s, and who saved the life of pretty much every single patient whose life got saved in our emergency room, or about the anesthesiology resident who picked up on a case of tuberculosis a couple years ago here in Guatemala. I’m talking about a display of honesty and intellectual rigor that has had effects not just in the surgical world, but in the engineering world in general and in flight safety in particular.

In the 1970s, four anesthesiologists at Massachusetts General Hospital undertook a study of errors by members of their profession. 47 of their colleagues discussed with them–on tape–the errors that they had made in their careers. They talked about 359 incidents in total, of which 82% were caused by human error. As one commentator on that paper put it, Anesthesiology is the one domain in which patient safety was identified as a problem long before the Institute of Medicine’s 1999 wake up call to the healthcare community. Not only was the problem identified in the late 1970s, but anesthesiologists faced the issues, taking actions to effect changes that would reduce errors, adverse outcomes, and injuries. While it is often difficult to trace the historical path of change, there is reason to believe that the anesthesia critical incident studies planted seeds of ideas for others, either directly or subliminally.

Along with later work on equipment problems in anesthesia that proceeded on the same methodology, this body of research set the standard for a broad field of research in engineering on how to understand problems with systems, and how to use your understanding of those problems to make those systems safer. Table 3 in that paper gives nice insight into how that works. It shows the distribution of frequent types of equipment-related errors; one thing that you notice there is how many of the frequent categories of problems are related to misconnections or disconnections of the various and sundry tubing systems involved. One of the responses to this finding was to make it mandatory to have connectors on medical gas systems that cannot be plugged into the wrong gas supply–today, it is mechanically impossible to plug your oxygen line into a “room air” supply, or your room air supply into a vacuum. Today’s anesthesia machines are one of the best-designed kinds of systems for supporting a human life on this planet, and the anesthesiologist’s approach to thinking about what he or she does is ubiquitous in fields as diverse as flight safety—and surgery. As Atul Gawande put it in his book The checklist manifesto, describing the ways that checklists are used to help a pilot and co-pilot work together to recover from a potentially fatal emergency: as integral to a successful flight as anesthesiologists are to a successful operation.  Step back for a second and think about where these advances came from: anesthesiologists admitting to other people what they did wrong, on the record.  I wish that I had that kind of courage.

Room air hose. Picture source: dremed.com.

Oxygen hose fitting. Picture source: dremed.com.

Hose connector for nitrous oxide. Picture source: dremed.com.

Connectors for the hoses for four different kinds of gases.  It’s not physically possible to plug these hoses into the wrong source–a product of those studies by anesthesiologists.

I woke up when my surgery ended, poorer by four molars but with an increased appreciation for what anesthesia and anesthesiologists bring to the world.  When our patients wake up here in Guatemala, it’s usually with their lives changed–Monday’s reconstruction of a hand for a teenager who I’ve seen every one of the five years that I’ve been coming here, as it’s a complicated surgery that has to be done in stages; yesterday’s removal of a mass on the right wrist of a woman whose job involves writing with a pen all day, and who therefore was losing the ability to support herself in a country in which there is no such thing as unemployment insurance, or disability support for people who can’t work; Tuesday’s repair of a cleft lip for a kid who otherwise would have been unlikely to find a spouse, in a country in which your only social support net is your family…

Enjoying these posts from Guatemala?  Why not make a small donation to Surgicorps International, the group with which I come here?  You wouldn’t believe how much aspirin we can hand out for the cost of a large meal at McDonald‘s–click here to donate.  Us volunteers pay our own way–all of your donations go to covering the cost of surgical supplies, housing for patients’ families while their loved one is in the hospital, medications, and the like.

English notes

Trailer trash: Here’s Wikipedia’s definition of this very American term: Trailer trash (or trailer park trash) is a derogatory North American English term for poor people living in a trailer or a mobile home.[1][2] It is particularly used to denigrate white people living in such circumstances[3] and can be considered to fall within the category of racial slurs.[4] The term has increasingly replaced “white trash” in public and television usage.

How I used it in the post: When I was a kid, I liked to do drugs as much as the next trailer trash, but I never, never understood how someone could stick a needle in their arm–until I had my wisdom teeth out.

The full description of Fanny Burney’s surgery

Here are the two paragraphs of Fanny Burney’s letter to her sister describing her surgery.  There’s more to the letter, which also describes the whole process of the development and diagnosis of her breast cancer–there’s a link to it at the end of the post.

My dearest Esther,—and all my dears to whom she communicates this doleful ditty, will rejoice to hear that this resolution once taken, was firmly adhered to, in defiance of a terror that surpasses all description, and the most torturing pain. Yet—when the dreadful steel was plunged into the breast—cutting through veins—arteries—flesh—nerves—I needed no injunctions not to restrain my cries. I began a scream that lasted unintermittingly during the whole time of the incision—and I almost marvel that it rings not in my Ears still! so excruciating was the agony. When the wound was made, and the instrument was withdrawn, the pain seemed undiminished, for the air that suddenly rushed into those delicate parts felt like a mass of minute but sharp and forked poniards, that were tearing the edges of the wound—but when again I felt the instrument—describing a curve—cutting against the grain, if I may so say, while the flesh resisted in a manner so forcible as to oppose and tire the hand of the operator, who was forced to change from the right to the left—then, indeed, I thought I must have expired.

I attempted no more to open my Eyes,—they felt as if hermetically shut, and so firmly closed, that the Eyelids seemed indented into the Cheeks. The instrument this second time withdrawn, I concluded the operation over—Oh no! presently the terrible cutting was renewed—and worse than ever, to separate the bottom, the foundation of this dreadful gland from the parts to which it adhered—Again all description would be baffled—yet again all was not over,—Dr Larry rested but his own hand, and—Oh Heaven!—I then felt the Knife rackling against the breast bone—scraping it!—This performed, while I yet remained in utterly speechless torture, I heard the Voice of Mr Larry,—(all others guarded a dead silence) in a tone nearly tragic, desire everyone present to pronounce if anything more remained to be done; The general voice was Yes,—but the finger of Mr Dubois—which I literally felt elevated over the wound, though I saw nothing, and though he touched nothing, so indescribably sensitive was the spot—pointed to some further requisition—and again began the scraping!—and, after this, Dr Moreau thought he discerned a peccant attom (fragments of diseased [peccant] breast tissue)—and still, and still, M. Dubois demanded attom after attom.

Web site with Fanny Burney’s letter http://newjacksonianblog.blogspot.com/2010/12/breast-cancer-in-1811-fanny-burneys.html

Blog about pre-anesthesia surgery https://thechirurgeonsapprentice.com/2014/07/16/the-horrors-of-pre-anaesthetic-surgery/

https://en.wikipedia.org/wiki/Frances_Burney