Today I am happy to submit for your appreciation a true story. In some tales you hear the line the facts are true only the names have been changed. That applies to the “Road Trip” which was written as a sort of autobiographical recount from a long time CRNA (Certified Registered Nurse Anesthetist). I hope that you enjoy this example of what it is like to be an anesthesia provider behind the scenes doing the every day work of an anesthetist. In reality this is something about being a rural CRNA keeping your finger in the dike, working hard to keep your skills up for when it really hits the fan; something about being “on deck” for half of your life knowing that in fact for 65% of rural hospitals, CRNAs do this “Road Trip” night after night. Enjoy. For those that wish more information about CRNA clinical practice I refer you to the professional organization at the national level – the AANA.

Road Trip

“Damn, damn DAMN!” He thought. Two seconds ago, he’d been rushing across the hospital parking lot, thinking about all the things that could go wrong during an emergency anesthetic for a 400 pound patient, and all the things he’d have to do to make sure that none of those things would go wrong. Ten minutes ago, he’d been writing some last-minute Christmas emails and thinking about yet another New Year resolution to send cards next year.

As the initial shock and anger began to wear off, the hard reality of the slick, cold, gritty black ice of the parking lot began to make itself felt. His right arm hurt like a son-of-a-bitch, and when he tried to flex it, it wobbled uneasily, but bent very nearly as it should. “Nothing broken”, he thought as he picked himself up gingerly off the pavement and fumbled for his ID tag to let himself into the back door.

The reality of winter in the northland hit him, and he reflected that you could take the boy out of California, but you couldn’t take California out of the boy, and that, as long as he had lived in the North Weeds, he still had to remind himself that the footing could be treacherous. Then the reality of the life of a rural CRNA came back to the fore, and his mind tore itself away from the pain, and back to planning for the care of his patient

“Murphy”, he thought, “was an optimist”. What had started as a simple in-and-out look through a scope at the lining of his sedated patient’s stomach had turned into a desperate emergency. The high-resolution screen of the video system hooked up to the modern gastroscope had told the tale for the entire crew to see – a crimson geyser sprayed from a tiny hole in the lining of the man’s stomach. Under the magnification of the fiberoptic system of the scope, it looked horrible. “We have to open”, said the surgeon. Just like that.

“No plan survives initial contact with the enemy”, he remembered from somewhere in his past. That spout of blood was trying to kill this man, and the entire crew stopped and looked at him there at the head of the table, and he suddenly felt very alone. Quickly, he ran a mental checklist for a “rapid sequence IV induction”, a procedure that would quickly and safely exchange the patient’s fuzzy panic for calm sleep, and exchange the poor man’s labored breathing for the efficient mechanical swishing of a modern anesthesia ventilator pumping life-giving oxygen into the man’s lungs along with general anesthesia – the mysterious miracle that has been called “death with a return ticket”.

Years of practice and training informed his quick and efficient movements. Everything was laid out exactly where he knew it would be because everything was ALWAYS laid out where he knew it would be. Years of working alone in operating rooms where everything that could go wrong frequently did go wrong had prepared him to prepare. Even in preparation for the most seemingly trivial procedure, everything that might be needed was there. He knew that, sooner or later, everything that might be needed would be needed. Decades ago, he’d learned that, while there might be “minor surgery”, there was no “minor anesthesia”. In a series of steps that would have occupied several pages of some systems analyst’s flowcharts, but which took only precious seconds, his patient was asleep, a tube safely and surely in his windpipe, his blood pressure and pulse stabilized. With a terse nod to the surgeon and the man’s family doctor who’d been urgently summoned to help, he said “Go”. The incision was a small white rent in the yellow of the iodine-stained skin for a split second, and then drops of blood became a thick red line as the doctors went to work. He scanned all his monitors again, satisfied that his patient was responding as he should. Only then did he reach for the phone.

His partner of several years was home, and he breathed a sigh of relief as she answered the phone. A second pair of educated hands would be a life-saver – perhaps literally tonight. “Damn — I’m a one-armed bandit”, he thought to himself silently as he grunted with the effort of hanging another bag of IV fluid with his arm that did what it was told, but reluctantly and painfully. He could have finished this case alone, but he didn’t have to prove that to anyone, least of all to himself.

Within minutes the other CRNA had come. No questions asked no protestations that it was her night off – because it had often been the other way around and she knew it would be again. With a brief exchange of questions and answers that a visitor might have mistaken for a foreign language, he brought his partner “up to speed”. The doctors, heads nearly bumping over the deep incision into the man’s massive abdomen, murmured in a language all their own and the technician and nurse half-listened, preparing and handing instruments in a frenzy of movements that spoke of years of having done this. A hundred collective years of training and experience came together over the man’s blue-draped body, homing with a grim intensity on that “bleeder”, conspiring to cheat Death yet again.

The two CRNAs worked together in the small area between the head of the bed, the cart full of drugs and equipment, and the anesthesia machine. In a space barely big enough to turn around, they divided the tasks and worked together with a silence broken only by an occasional syllable or two; they both knew what had to be done. Within minutes, another large IV needle was in a vein in the man’s arm, and a slim needle had been run up an artery in the man’s wrist to monitor his blood pressure. With each task completed, their pace became less frantic but no less intense.

Finally, the doctors looked up. “Got it”, said the surgeon, and for the first time, he took a deep breath. “We’re closing him up, and you guys wake him up and we’ll transfer him”. The CRNAs looked at each other, and each knew what the other was thinking. This desperately ill man would “wake up”, all right, but it would be tomorrow, miles away, in an Intensive Care Unit, of which this tiny rural hospital had none. They also knew that the same freezing drizzle that had turned the skating lot into a parking rink would have kept the helicopters parked safely in some hangar somewhere, and that it would be a long and careful trip in the back of an ambulance.

One general anesthetic, with everything, to go.

The ride was long and bumpy. Each breath for the patient came from a plastic football-shaped bag, squeezed by his beat-up sore arm. He thought it would never end, but like everything else in his career, it did.