This is a famous quote by Ralph Carpenter which was misquoted by Yogi Bera. (It ain't over til it's over) But, I digress. This post is not about baseball. It is, unsurprisingly, about anesthesia. I will paraphrase the quote: "The patient is not asleep until he/she is asleep."
It's two in the AM. The next patient is waiting for an orthopedic operation. The nurses inform me he is a 50 year old IV drug abuser. From across the room, I see the patient's chart, the problem list is a mile long and looks like a rap sheet. That seems odd, I would expect such a thing in an elderly patient. I get closer and see that every single diagnosis is trauma related. This man has literally broken every bone in his body, one at a time.
Not only is he a drug addict, but he is a thief as well, and quite bad at it. All his trauma is related to his illegal habit of supporting his habit. And each time he jumps or falls off of roofs or balconies, he breaks a bone and is hospitalized. Oh, that's quaint, I see he's also been shot (by the police, no doubt) and stabbed (by his fellow inmates I suppose).
He is asleep, so I nudge him awake and tell him it's time for his operation. He starts whining that he needs his methadone (a substitute for heroin which alleviates the craving for the drug), he was promised methadone, and he's not having his operation without his methadone. I tell him that we don't have methadone in the OR but I will give him a proper alternative. "No, No, I want methadone , Dr. ----- promised me. "Well, Dr. ----- isn't here, it's 2 AM and I the king of the ant hill right now, so relax and let us take care of you."
I must say, that to my advantage, he had a broken leg, so he wasn't about to run out on me. We wheeled him into the OR; all the while he was bitching and moaning about his methadone. Did I mention that drug addicts are my least favorite patients? At that hour of the night I'm not always able to conceal my feelings.
After attaching the monitors, I begin induction of anesthesia, I start with midazolam (an anxiolytic) and then fentanyl (an opiate) and finally propofol (a hypnotic). The surgeon was studying the x-ray films and then turned towards us and asked the patient a question, completely oblivious that induction had begun. When the patient didn't respond he said, "Oh, he's already asleep?". "Yeah" I said, "the whiney jerk is under."
Suddenly, the patient lifted his head, "Whiney, jerk? Who are you calling a ...."
An extra dose of propofol, and a nice smattering of succinylcholine (a muscle relaxant) and this time he really was asleep.
Luckily, the midazolam also causes amnesia, so he won't remember the memorable proceedings.
So, anyway,like I said, he ain't asleep until he's asleep....