July 5, 1977, at Mt. Diablo Hospital in Concord, California, I stood ready to give my first anesthetic in private practice.
Several years earlier, on the very first day of his residency, on his first case, one of the Stanford residents had a child die from malignant hyperthermia (MH). (The antidote, Dantrolene, was not introduced until many years later.)
This unlucky resident’s liability insurance carrier even tried (but failed) to rate his private practice policy based on this hugely unfortunate experience.
My good fortune was to have started and finished my Stanford residency without ever seeing an MH case. However, I was hoping to get through my first private practice case without any such bad luck, too.
There I stood awaiting the arrival of plastic surgeon, Hale Tolleth, M.D. He was an hour late…
He introduced himself to me then explained the facial surgery case would take the whole day, but he did not want me to intubate the patient, ‘just’ sedate her.
There I was, prepared to anesthetize any cardiac case including a transplant but was being asked to provide a service about which I knew nothing.
During my residency, I had given intravenous sedation for cases as long as 45 minutes, typically with diazepam and meperidine.
I had never heard, read about, or had presented a ‘game plan’ of sedation for an 8 hour case.
Welcome to private practice, Dr. Friedberg, I thought.
After giving the problem some consideration, I guessed at what might provide the conditions for which my surgeon asked.
I took a 500cc bottle of saline, injected 500 mg thiopental and 100 mg meperidine, spiked the bottle with a 60 drop per cc set, gave some nasal oxygen & proceeded to titrate the patient.
She was in a semi-sitting position. The surgeon must have been very good with local anesthesia because I have no recollection of the patient moving or him re-injecting.
Another unique moment happened about half way through the case. Tolleth looked over to me and asked what I would like for lunch. I thought surely he must be teasing me. Having lunch was never a consideration during my 2-year residency.
I thought I would return the tease saying ‘lox and bagel would be just fine.’ To my astonishment, the surgeon told the nurse to fill my request and bring him his ‘usual.’
About 30 minutes later, in came the nurse with both lunch orders. My surgeon removed his gloves and we sat down and ate our lunch.
Never in the ensuing 34 years have I had such an experience.
Never lost the airway through the entire facelift, etc. case.
Needless to say, though, the patient was so hung over at the case’s end, she spent the night in the hospital. In 1977, no one thought it was an odd outcome after an 8-hour surgery.
However, I thought it would be really wonderful to have a drug that would go away after a case like that. Propofol was not introduced until 1989. We had no pulse oximeter until 1984.
As I think back over the triumphs and disasters through which I have persevered, I would have surely been incredulous if anyone would have told me I would author not one, but two books, receive a US Congressional award as recognition for contributing to the anesthesia safety of wounded troops in the forward units and create a non-profit foundation to promote patient awareness of the critical need for brain monitoring during anesthesia.
As the song goes, “What a long strange trip it’s been.”
Thank you for sharing this moment in history with me.