If in the normal course of a hospital stay you needed to have surgery, the anesthesia that was provided for you was not rolled into the room costs – it was an itemized charge tacked on end of the hospital’s bill – Think mini-bar, not mint on the pillow. You didn’t hire an individual to provide anesthesia, you contracted a group to do it, which then billed for the service they provided any old damn way they wanted to.
Anesthesia was an added service provided to the hospital by an outside business as a courtesy -- evidentially so you wouldn’t have to provide it yourself. Insurance companies would often pay a portion of the Anesthesiologists bill, but only the amount they considered “reasonable,” and this amount was rarely in the ballpark of what you were actually being charged for it. Since the anesthesiologists, and their group, had a monopoly on providing the service, and since surgeons had stopped cutting people centuries ago without using anesthesia, your options were limited to paying in cash or making payments on a credit card.
Each anesthesia group was exclusive, and a closed shop—only its members could provide anesthesia, and only in the hospital that they had contracted with. As a group, they would make deals with individual hospitals to provide them with all and every anesthesia need at no cost to the hospital. In return, they would be considered by the hospital to be contractors providing an outside service, and as a result, not be subjected to fee schedules or restrictions on the prices they could charge. When you pick up a complimentary copy of Newsweek in the doctors office and find a report on which Physician specialties make the most money, don’t be surprised when you see that Anesthesiologists are the best-paid physicians in America. It’s not even close, and now you have your reason.
By day, Anesthesiologists wore masks and hid in secret lairs that were restricted and unavailable to the public. At night, they did their people thing - the pre-op visitations and follow-up chart documentation, all those things necessary for both accurate billing and rough dosage calculations. Think: vampires on a dark night looking for slow moving cows to feed on.
Like most doctors, they tended to be quiet when they came to the Unit; you’d see them only if you were looking directly at the patient’s chart as they stole it away to evaluate the numbers in the safety of a cubby hole. (Oh, and they left no reflections in mirrors.) They seldom stopped and talked to nurses, they didn’t need to, all they really needed was the information in the numbers, and this they could get from reviewing the chart without talking to anyone.
Anesthesiologists were a spooky bunch, and not in that physics, spooky-action-at-a-distance way, they were more like the Jason of the Halloween movies —Relentlessly prowling late at night with a mask on kind of spooky.
They saw patients at night because they busy working all day knocking people out with heavy hits of drugs and gas. It was a science to them but the difference between that and witchcraft was not an obvious one to the casual observer.
Dr. Y was a good example.
In the morning he would head down to the Pharmacy with a little grey lock box. He would enter it through the back door, using the private pass key that he had been issued, and nod a good morning to the head pharmacist. The Pharmacist would take this nod as a command and open up a safe full of hard narcotics. The anesthesiologist would then load up his box with, literally, ounces of narcotics in various shapes and form, and then signed for in them in bulk and return to the safety of his lair.
Nice work if you can get it.
At some point in his workday, at a time that was never seen by others, those narcotics were mysteriously transferred into syringes that would sit, poking plungers exposed, in a white lab coat for the remainder of the day.
I always thought that Dr. Y used syringes as a conversational aide when talking with his patients. He’d ask a question, shoot some dope, then check to see if they talked a little less with the next question.
And, it was mix and match—that’s why he had so many syringes—a little of this, a little of that – a conceptual approach also known as “titrate for effect.”
I think that there were two reasons why his syringes went unlabeled: to enhance the mysticism of his work to others, and to reinforce in himself the god like powers he produced from the tips of his fingers.
And, he did it as a way to kind of spice things up by introducing a little random chaos into his daily life.
Dr. Y’s bedside manner consisted of grunts and giggles, presented as a flyby of words —a rushing, swooping out of nowhere kind of conversational style in combination with a showing-up-at-the-last-minute hurry of breathless excitement – all in a mish mash of poor pacing and indirect questioning, that usually ended with a yes or no to all questions, delivered with a dramatically clipped form of impatient brevity, as if even his yes or no was in danger of falling off the edge of the world as he was trying to leave them in the room and was afraid they wouldn’t stay put as he rushed away.
He mumbled when he talked, and looked only at the machines in the room when asking questions. He was psychologically wall-eyed – you never knew which part of his minds eye was actually looking at you, or really, why. You also never knew what part of his head to look back at when you answered him—the inability to focus on a point of him when he spoke made eyes turn twitchy and the any accuracy of what he was saying random.
In the end, he expressed his feelings with narcotics. He was a small g god, well juiced with the magic, but flawed in directional aptitude.
Dr. Y talked to Mr. Posey, as I stood by and watched anxiously. Using acronyms sandwiched between passively modified verbs, he alluded to problems that Mr. Posey may, or may not have. His sharp, immediate and drastic solution to these problems fell from his mouth in verbal shadow play of misdirection. He wasn’t selling snake oil, he wasn’t selling anything, and there wasn’t any reason for his misdirection, we were all on the same page anyway – he was just killing time until he could knock Posey out, to finish the job and then leave.
As I bitched to myself about the impersonal way Dr. Y was treating Posey, I was also starting to treat him as more as a problem than a person. As his responsiveness and awareness went downhill, I found myself making decisions for him based on what I thought was best, rather than what I thought his wishes might be. I began to stop filtering decisions though him. I started to think of myself as his medical proxy. In my head, what was going on with him had changed from, “What would he want me to do,” to, “What should he want me to do.”
One word, big difference, but I didn’t think I was wrong, I just thought I was doing what was necessary.
I had explained to Posey the procedure of intubation instead of offering him options about it. He could have been a bed railing for the quality of the explanation I gave. It was if I was going through the motions with him. I told him what I wanted him to hear as if I were fulfilling a legal requirement, without giving him enough time or information to figure it out for himself. I didn’t lead him to an answer; I led him to my conclusion
From the moment of my epiphany earlier in the day -- that point were I had seized control of Posey’s care -- I had a problem, a circular dilemma that revolved around my knowing much more than he did. I was smarter, so my decisions had to be better than his. The problem: the bet on the line was him, not me. I was taking the responsibility for the action, without accepting the results of the consequences. He was the one with the medical problem. I was the one going home at the end of the day no matter what happened.
What was happening: the power and control of the decision-making had shifted from Posey to me. The cost of this was the loss of my distance and detachment. Without that ability to stand apart from-- that perspective -- the fear of not getting what I wanted, or losing what I thought I had --began to drive me. I began to see Posey’s survival as a challenge to my skills—a battle against the forces of death, and that I was a Luke Skywalker, and standing alone against the evil empire. Some part of me knew this was happening, but not the part that was running the show.
I talked to Mr. Posey and he listened. I took control. I told him that I wanted him to see his wife before we intubated him, and that this might be the last time he got to talk to her. I told him that we would give him more sedation to knock him out, at least a little, and that he wouldn’t be able to talk after the tube was put in. And I told him that this all needed to happen fast—that without the tube breathing he would not be able to continue breathing on his own for very long.
Still dopy from the Valium I had given him earlier, he didn’t ask me any questions, and he didn’t say no. His breathing was so labored and loud at this point that his ability to make decisions had left him. It was about surviving for him—complexity, reflection and choice were no longer part of his awareness.
I told Dr. K that Mr. Posey’s wife was in the waiting room and said he needed to give her an update before doing anything. He said he’d do it after the intubation.
I told him it would take a while to set things up, and that since she was active in Mr. Posey’s care, I wouldn’t be comfortable without her getting an update. I also sort of suggested that she was the kind of person who might make a really big stink and the type who would make eye contact with him for a long time if he didn’t talk to her first.
Dr. Y said he’d be right back, and left for the waiting room. When he returned, she was with him.
Mrs. Posey entered the room with Dr. Y. The look on her face was one of concern but distance—as if she were thinking hard about something to be found in another room. She approached the bed and took both of Mr. Posey’s hands into her own, and asked no questions, just held his hands and looked at him, and slightly above him. He nodded at her and attempted to smile under the non-rebreather mask, and scrunched a little up in bed to position him to see her better. It looked as if he doing all this for her, but it was hard to tell, it wasn’t much.
The light in the room got brighter, the machines quieter, and the mood lifted. Dr. K left the room after mumbling a quick, uncomfortable “be right back,” and I stepped closer to the bed to catch a whiff of the feeling between them. The clarity in the room made the bigness of it all a little sharper. What was going on wasn’t about me, it wasn’t really even about them—it was a moment, a pause in time when everything was a print to be saved—no shadows, no dark corners, just a holographic memory of the now being stamped and frozen in real time.
But it wasn’t just a memory for later—it was something larger than memory- it was a moment in the now that was fully acknowledged and accepted without any thought to what was to come of what had come before. It was an unconditional surrender to time and place. We were here and this was now, and nothing else existed.
And then it moved, and jerked and the machinery of times arrow geared up again. The lights dimmed, the noise rushed back, and Mrs. Posey started to cry. Always forward, this time thing, progressing and leaving behind things that should be forever held in safe places. And her crying became sobs, big breathless sobs of too much—as if the effort to hold on had exhausted every ounce of control she had brought with her into the room.
Mr. Posey looked up to her using only his eyes; his head was bent by pillows and the effort to move any more than his eyes were too much. His hands let go of her, his eyes fell, and he stopped responding to her.
Dr. Y, as the moment broke, started explaining the procedure to her. As he talked, Posey opened his eyes a little and followed her with them, but did not say anything. After a minute, she kissed him and walked out of the room, again, without acknowledging either of us, or what we were doing.
All the stuff Dr. Y said to her was a nothing of a thing, a package of big words, all of them calculated and deniable, just a thing to do as he adjusted machinery and wrote casual notes in Posey’s chart.
Studiously not looking at Posey after his wife left, Dr. Y. paused, hemmed and hawed, and then he looked at me and motioned that he wanted the bed be flattened. With the headboard removed and the bed elevated enough to prevent back strain, Dr. Y opened the intubation tray and placed each item in front of him. He looked directly at the monitor as he covered Posey’s eyes with a towel.
Mr. Posey looked at me until he couldn’t, and I gave him another dose of Valium.