Listening to my Spidey-sense...

March 25, 2023

One day very early in my career as an attending anesthesiologist, perhaps five or six weeks out of my residency training, I had a case which was very upsetting to me.

I went to the patient floor in the late afternoon to see my preoperative patient for the next day, and was accosted by the Physician's Assistant for the vascular surgery service, an alert Chinese-American guy named Quinn. He saw me, and immediately said "I don't think Galvin is going to do his first case". It was booked as a carotid endarterectomy on an asymptomatic patient. My Spidey-sense began to tingle with some good reasons NOT to do carotid surgery on an asymptomatic patient, for example, there was no immediate way to gauge the success of the operation if there were no symptoms. (The term "Spidey-sense” is derived from the popular Marvel comic character, and refers to an instinct or sense of alarm that Spiderman has when something is wrong.) Dr. Galvin, who was chief of the department, had evidently made asymptomatic carotids a specialty of his. "He had his other side done last year, asymptomatic, and ended up with a permanent vocal cord paralysis on that side. I don't think Galvin will risk bagging the second side too." Because it seemed unlikely that the case was going to proceed, I decided not to interview the patient, but asked Tom and the patient's nurse to call me at home if Galvin was not going to cancel the case. I did interview the second patient on the schedule, who was also booked for an asymptomatic carotid.

I had never been faced with a bilateral vocal cord paralysis, but thought of the potential consequences. Would the patient be able to speak? Would he be able to protect his airway against aspiration? Would he be able to eat? Would he need a gastrostomy tube for the rest of his life? Would he need a tracheostomy? It was an unusual scenario, but none of the possible outcomes seemed good. I couldn't imagine that Dr. Galvin would proceed with the case. I went home.

By nine o'clock I had not heard from Quinn or the nurse, and I called the floor. No, the case had not been cancelled. The tingling of my Spidey-sense became more urgent. What should I do?

I could wait until the morning to talk with Galvin (who did not know me from a hole in the wall) about his reasons for doing the case, but it seemed to me that that discussion might be rushed and pressured. Damn, I should have called the floor earlier. My requests had fallen through the cracks. However, the patient shouldn't suffer from my mistake.

I called the hospital operator and asked her if Dr. Galvin was on call. He wasn't. I took a deep breath and asked her to put me through to his home phone.

He answered on the second ring. "Hello?" "Dr. Galvin, my name is Dr. Ed Koh, and I am the anesthesiologist for your two carotid cases tomorrow. I'm sorry to call you so late, but I wanted to ask you what your thinking was in doing Mr. Finkel given the vocal cord paralysis from his surgery last year."

You could have heard a pin drop. "What time is it, nine thirty? What are you doing calling me at this hour at my home with this kind of a question? Do you know WHO I AM?" "Yes, you are the chief of ..." "I am the chairman of the department of vascular surgery, and I have performed hundreds, probably over a thousand of these procedures over the past twenty-five years. In that time I have NEVER had a complication."

My own experience with carotid surgery was very slim. In fact, I don't know if I had done a single one in my two-year residency. The vascular surgeon where I trained was very conservative about doing carotid endarterectomies, and so, between the ten residents in my year, we did very few of them.

I did remember being called during my internship to the room of a middle-aged woman who was having projectile vomiting and a sky-high blood pressure (240/140). She had had a carotid endarterectomy that afternoon, about six hours before, and had been doing fine. I tried treating her hypertension with Inderal, which the young neurology attending later told me may have been a mistake, and we sent her for a stat head CAT scan. It showed that she had bled into her putamen (deep in her forebrain), and she died that night. Upon reflection, that incident had little to do with the technical aspects of her surgery, and everything to do with the fact that she had had the operation at all. How could a surgeon claim to have a ZERO complication rate over a thousand of these cases?

This memory came to me later on. During the phone call I felt simply run over by the steamroller of Galvin's indignant anger and sense of entitlement. Did I know who he was? Only later did I learn that the Surgical Intensive Care Unit (SICU) had been named in his honor, that it had a plaque with his name on it at its entrance! (At the time I was also too naive to realize that the naming had probably been the result of a gift to the medical center of at least a million dollars on his part.)

By the end of the ten-minute phone call I felt like two cents. Here I was, wet behind the ears, barely out of my residency, questioning the decision of a grand old man in the medical school, a man with white hair who wore a tie and a buttoned-down long white coat to see his patients, not a pair of surgical scrubs. I told Carol what had happened, and she tried to reassure me. I went to sleep but slept poorly.

At six in the morning I still felt like shit. I went in to work and avoided Galvin's haughty gaze.

During the case I stood in my normal place, to the left of the patient's head. My nurse anesthetist was standing at the head of the bed, "doing the case". Rick Johnson was in my book the best CRNA in the department, and he was relaxed and did his job with a confident flair. He had done many carotids, and it was my unspoken job to learn from him. He started an A-line (arterial line for blood pressure monitoring and blood draws), and we each started an iv (intravenous line).

Galvin was standing directly in front of me, in the surgical supervisor's position, while the vascular fellow was the primary surgeon. They got to work.

It was clear from the start that to them this was just another day at the office. The case went without a hitch, starting with the EEG tech (electroencephalography technician to monitor brain waves) placing ten or fifteen needle electrodes under the skin across Mr. Finkel's scalp and neck. This was before our induction, but because of the sedative premedication Rick had given him it did not bother him. Rick and I had had a brief discussion about the previous night's phone call, and he had just rolled his eyes. We had done our preoperative workup rapidly, in about ten minutes, but beside the vocal cord paralysis there was nothing unexpected. I did notice that the patient's voice was hoarse.

The operation actually took only slightly more time than the EEG electrode placement. I learned that they routinely measured a stump pressure and then used a shunt, a piece of flexible plastic tubing, to maintain blood flow to the operative side. Together with the EEG monitoring, it was kind of a "belt and suspenders" approach, very safe. The most likely complication was breaking off a plaque during shunt placement, leading to an embolic stroke. Apparently that was rare.

When the case was done, Galvin shot me a casual look, like "See?", and left the room. If possible, I felt even smaller than I had the night before.

The second case started very similarly. EEG, anesthesia induction, shunt placement, and incision. However, shortly after incision, the EEG tech came over and started to reach under the drapes, checking the tightness of his connections. "Sorry, Dr. Galvin. I seem to be having a technical problem." Galvin stepped back and was patient at first, but the interruptions continued every few minutes, and he began to get testy. "I'm having some kind of a problem, Dr. Galvin." "Well check your leads!" "I've checked them all several times." Galvin put his head down and continued working.

"Dr. Galvin, I need you to come and look at this." Galvin heaved a big sigh, then backed away from the field and went over to the EEG console. Even from my relatively remote position I could see the problem. The patient had lost voltage over all of the leads on the operative side, so that they were now flat lines.

When Galvin came back to the field he was sweating. He looked at the field. Everything looked fine.

The shunt formed a loop-the-loop connecting the proximal to the distal end of the artery. It was filled with blood, but there was otherwise no direct indication that there was actually flow through it. "It's not kinked..." Galvin said. He raised each end a fraction of an inch. "There! You did something! I'm not sure, but I think some voltages are coming back! Yes, they're coming back up again!" said the tech. The whole room breathed a collective sigh, and the surgeons went back to work.

I noticed that Galvin's sweating did not go away. In fact it got worse. The implications of what had just happened sank in to me. The flat lines on the EEG had not been an electrical artifact. Half of the patient's brain had been deprived of blood flow for up to a half an hour. Galvin's worry was that the patient might not wake up, or would wake up with a huge hemipheric stroke. We would not know until the procedure was done. He worked fast.

As I saw Galvin sweat profusely, I was overtaken with a wave of anger. No complications in a thousand cases? Bullshit! This incident was due to a flaw in his technique, and could have happened to any of his patients, including Mr. Finkel! Our heads were two feet apart, and I could feel my anger searing the air between us.

Rick had pointed out to me in the morning that the vascular surgery department had four surgeons, all of whom were very busy. They would admit a patient with a vascular symptom, say claudication in the legs, and shoot a series of angiograms all over their body, including their ascending and descending aorta and both carotid arteries. Even if the patient had no other symptoms, if significant stenoses were found they would book them for bypass operations and endarterectomies, "prophylactically". Later on I heard the sarcastic term "rectangle of Vascular" (rather than the circle of Willis), ax-ax-fem-fem-ax bypasses (axillary-femoral) for every patient. The fact that their underlying disease, including often coronary disease, put them at high perioperative risk was offset by the argument that they did not have any complications.

Rick told me that they had done an abdominal aortic aneurysm the week before on a man who then suffered a postop MI (myocardial infarction). The patient did poorly. The vascular service blamed the MI on poor fluid management by the anesthesia department.

This explained why their numbers were so good. If they were keeping their own statistics, and blaming complications on others, then of course the number of complications they reported would be very low.

The whole thing was a racket, a cynical exploitation of a very sick group of patients, and their families.

The patient woke up normally, without a lateralized deficit, and Galvin was relieved, though by now drenched with sweat.

I went to Henry, our "board runner" or clinical chief, the most respected member of our department. "Henry, I do not want to do any more of these asymptomatic carotid cases." I told him about Mr. Finkel and our near-miss case. He listened carefully. "I'll talk it over with Dr. Smithfield." Smithfield was the chief of the department.

An hour later I was summoned to Smithfield's office. "Well I've talked it over with Henry, and we've decided to grant your request this time. However, I have to warn you that anesthesiologists who make these kind of requests do not tend to have very long careers."

Ignoring this thinly-veiled threat, I left his office and breathed a sigh of relief. Henry was good to his word and didn't assign me any more asymptomatic carotid cases. The following year, Smithfield told me that he was not renewing my contract.

Years later, an article written by a prominent Boston neurologist concluded that, after a large study, carotid surgery had a slight advantage over medical management alone in asymptomatic patients. So Galvin had been right and I had been wrong.

However, on further reflection, I realized that Mr. Finkel's case was one-of-a-kind. How often did carotid surgery lead to vocal cord paralysis, and how often would a surgeon then take the risk of causing a bilateral paralysis? The Boston paper addressed a very large cohort of patients, but that said nothing about this very unusual case. (In retrospect, Mr. Finkel's first case alone disproved Galvin's claim of never having a complication: a vocal cord paralysis is a significant complication.)

My Spidey-sense had alerted me to the possibility that Galvin's decisions were not being made based on his patients' welfare, but on some other factor, like his own status, or perhaps even greed. When I asked him to tell me his reasoning, he answered "Do you know who I am?" instead of discussing the case on its merits. I felt that he was hiding behind his name, his reputation. The idea that he had set up this cynical money-making machine was abhorrent to me. I had no desire to be a cog in his machine.

In later years I was gratified to learn that Henry had been named chief of the anesthesia department.

My Spidey-sense continued to get me into frequent scrapes with surgeons over the years, so much so that I often asked myself if I had a compulsion to get into trouble. Over time I realized that my Spidey-sense was really my sense of right and wrong, which had been taught to us by our parents over the course of our childhood. Every day over dinner, my dad would recount in detail some fight he had had that day with the dean of his college. The punchline would always be "And then I said, Mr. Dean, you son-of-bitch!!" "Daddy, don't say that!" my mom would say, but she had similar ongoing problems with her bosses, and had to repeatedly justify her existence by bringing in more grant money. Both of my parents were not obedient employees, and I learned this attribute from them.

I don't know why some of my colleagues learned to "play the game" better than I did, but over the years, I saw their careers skyrocket while mine foundered. I abandoned my academic career, at least partly due to my newly-diagnosed bipolar disease. This was the secret burden that I carried for the rest of my clinical career, which I spent bouncing around in the community every four years or so. Many of my “transitions” were the result of run-ins with powerful surgeons. Would I never learn? Over the years, my family was subjected to one emotional and financial trauma after another. Carol supported me through it all, even a horrible stretch where I lost touch with reality due to a psychotropic drug side effect and turned my back on our love.

Through it all, I cursed my Spidey-sense. The incidents did not go away, but actually became more frequent as the medical environment changed into a more factory-like, less patient-oriented system.

************************

June 27, 2025

The final case of my thirty-six year anesthesia career went as follows: An orthopedic surgeon that I liked, Mike, had booked a bipolar hip prosthesis on an elderly nursing home patient whose mental baseline consisted of being nonverbal and barely responsive to any stimuli. I took him aside and asked him why he was doing the case. “She has pain when they reposition her in bed,” he said. “The nurses and aides have been complaining to me about it.”

The lady had a bad cardiac history: multiple heart attacks and active coronary disease. I bit my lip and said to myself, “Okay, I know how to do this case. I’ve done them in my sleep at the big house. I’ll just do it the same way.”

An hour later we were in the room, and my patient was stable, intubated, and ventilated, being maintained on a very low level of anesthesia gas, and Mike’s team was working away. My thirty year-old boss Kevin came in. “You want some coffee, Ed? What are we doing here?” He looked at my monitors. “Ed, this is MAC awake!” MAC awake was a low concentration of gas at which 50% of patients would be awake, too low to maintain most patients. “Kevin, this is MAC awake for YOU, not for her. Her baseline is that she is barely conscious.” MAC awake was not an absolute number, but strongly influenced by factors such as age and state of health (or disease). I pointed to the BIS awareness monitor, which showed that she was asleep.

“Did you give her muscle relaxant?” “Oh yeah, I intubated her with Roc(uronium)! I forgot to chart it.” I wrote the dose onto the record.

“I want you to turn up the gas!” he said. “How high?” “Two percent!” I looked at him. “Kevin, you came in to give me a coffee break. Why don’t I go drink my coffee and come back in 15 minutes? Meanwhile, you can change the technique here in any way you want. When I come back I’ll finish the case your way.” He grunted a yes, and I left.

During my “break” I didn’t have a good feeling and couldn’t relax, so I cut it short after ten minutes and came back toward the operating room. When I reached the inner core area, I saw Kevin at the door yelling to get anyone’s attention. “What do you want, Kevin?” “Ed, get me some vasopressin!”

Vasopressin is an emergency drug which is only used in the direst of emergencies, like cardiac arrests. I went to the Pyxis drug machine, got out a vial of vasopressin, brought it back into the room, and handed it to Kevin.

When I returned to the room, all hell had broken loose. The patient’s blood pressure was 70 (systolic), her EKG was showing deeply sagging ST segments (indicative of myocardial ischemia or distress), the Sevoflurane vaporizer was delivering 2% anesthesia gas, and the Neo (phenylephrine) drip was running wide open. (Phenylephrine is a powerful vasoconstrictor used to support the blood pressure, and wide open is an uncontrolled attempt to deliver the highest dose possible.) The surgeons were working feverishly, looking very uncomfortable.

I looked at the chart. “When did you start the Neo?” “Oh, I forgot to chart it” he said, and scribbled the markings indicating a Neo drip onto the chart.

“I’ve gotta to check on some other rooms” Kevin said, and ran out the door. As soon as he was gone, Mike turned to me and said “Ed, we’re done.” I turned off everything but the oxygen (the anesthesia gas and the Neo drip) and woke the patient up.

Over ten minutes or so the lady’s blood pressure came back up to its baseline, 90 to 100 systolic, and she started to breathe on her own. Her EKG morphology reverted back to normal (i.e. her sagging ST segments rose back up to their baseline). She started bucking on the breathing tube (objecting to it), and I took it out. She was okay. We transferred her onto the recovery room stretcher and rolled her to the recovery room.

Kevin was waiting for me with two beepers in his hands. “Ed, why don’t you carry the code beepers.”

An hour later he paged me and called me into his office. My chart was spread out on the table. “Ed, I’ve shown this to two senior colleagues of ours, and we all agree that this is malpractice. Why don’t you take the day off tomorrow?”

The next day I got a call on my cellphone while I was walking into an appointment. It was Kevin, with an HR (human resources) woman on the other line. He proceeded to fire me without notice.

This was Wednesday, August 15, 2018, two days before my 65th birthday. On Friday I knew that Kevin was away for a company conference, so I went in to the hospital to clean out my locker and say goodbye to my friends, with whom I had only worked for a few months. Everyone was very sweet to me and wished me well. My friend Moses even made a small birthday cake for me and gave me a gift: a handmade glass bowl in shades of green, my favorite color. About five people sang Happy Birthday to me in the lunchroom. Then I took my cardboard box of belongings, turned my keys and ID badge in to Linda, and drove home.

I looked for a job for the next month without success and got quite depressed, and one month later, on September 15, suffered a major heart attack while attending an ovarian cancer conference with Carol in downtown Boston. Minutes later, on the cardiac cath(eterization) table at Tufts Medical Center, the situation degenerated into a full-fledged VFib (ventricular fibrillation) arrest. I was given CPR (cardiopulmonary resuscitation) for thirty-two minutes, shocked seven times, and finally put onto ECMO life support (heart-lung bypass) for nine days. Carol was given a ten percent chance that I would survive the night; I did survive, and stayed in the hospital for six weeks and a rehab(ilitation hospital) for another two. Carol brought me home the day before Thanksgiving, where I climbed our back deck with the aid of a walker.

This was an ignominious ending to a thirty-six year struggle to provide safe care to my patients, often fighting against the machinations of greedy, crooked, ambitious, or misguided surgeons, bosses, or hospital administrators. I often lost sleep at night worrying about how I was going to deal with these situations the next day, and this was not the last time I called an attending surgeon at home the night before their case.

Yes, my Spidey-sense was both a blessing and a curse. But, in the end, I didn’t have a choice. I had taken an oath to protect the safety of my patients above all else. That’s what made me a doctor, and I didn’t have a choice but to be true to that promise.

And so I did the right thing, each painful time, one grueling incident after another. (Further chapters to come.) Looking back, I am proud of myself and the decisions that I made. As my beloved dad used to say, I may not have always won, but I could say in my heart that I did my very best.

Thanks, friends, for reading.