Meet the doctors of sleep, images, and microscopes
Many surgical anesthesiologists, in fact, now refer to their field as perioperative ("in and around surgery") medicine, which might not be easier to pronounce than anesthesiology but helps capture the scope of their responsibilities. "It means we're managing all of our patients' medical problems while they happen to be going through one of the biggest stresses in life," says Apfelbaum.
Klafta and Schure start working on Christian as soon as he is rolled into operating room No. 13. Stationed at his head, they variously attach and insert an array of sensors onto and into his body to monitor his condition through the coming ordeal, including a catheter placed directly into the radial artery in his forearm to monitor blood pressure with every heartbeat. Christian had a heart attack and coronary bypass surgery last November, so special care has to be taken to detect--and treat--even the slightest signs of heart trouble.
Through an IV, they administer fentanyl, a powerful narcotic, to deaden pain, and propofol, a hypnotic, to induce sleep--minus any dreams or memories. Throughout the complicated procedure, which involves using some of Christian's own blood vessels and a Gore-Tex replacement as grafts to restore blood flow, the anesthesiologists remain at the patient's head. They monitor his condition, maintain his body temperature, and administer a wide range of drugs: before surgery, cisatracurium, a muscle para-lytic, to help ease a breathing tube into place. Later, a shot of ephedrine, to correct a dip in blood pressure. Heparin, an anticoagulant, to prevent blood clots during the long surgery. And more. The risk of death or major complication from surgical anesthesiology has plummeted 95 percent over the past 20 years, says Apfelbaum, thanks to education and improved training, more-sophisticated monitoring, and fast-acting "rescue" drugs that address dangerous swings in blood pressure and other potential catastrophes. "I'll go an entire day and only use meds that have been introduced since I started my training," says Klafta, who started medical school in 1990.
Meanwhile, there are 24 other operating rooms to worry about. Coordinating all the procedures is no easy thing, especially when emergencies bump scheduled surgeries from the roster. The job of "running the board" --calling for a blend of maître d' and air-traffic controller --almost always falls to an anesthesiologist. Today, it's Tom Cutter's turn. "Surgeons make the rules," he says, "but we are the keepers of the OR. This is our house." When problems arise, he says, "they call us and we triage stuff. It requires a fairly sophisticated medical understanding to figure out which patient is in the most dire condition." This particular day, that includes an urgent craniotomy for Elijah Norman, a 2-year-old with signs of fluid on the brain. Cutter decides to postpone an elective surgery to free up an operating room and contacts a pediatric anesthesiologist. Elijah will need an MRI before going to the OR, and the doctors decide to give him a mild sedative before the procedure; fidgety kids and imaging devices that demand stillness don't play well together.