Swiftly Dr. Billing squirted some topical anesthetic into the trachea, followed by the endotracheal tube. The laryngoscope made a characteristic metallic snap as Dr. Billing folded the blade onto the handle. With the help of a small syringe, he inflated the cuff on the endotracheal tube, providing a seal. Quickly he attached the tip of the rubber hose, without the face mask, to the open end of the endotracheal tube. As he compressed the ventilating bag, Nancy’s chest rose in a symmetrical fashion. Dr. Billing listened to Nancy’s chest with his stethoscope and was pleased. The entubation had been as characteristically smooth as expected. He was in total control of the patient’s respiratory state. He adjusted his flow meters and set the combination of halothane, nitrous oxide, and oxygen he wanted. A few pieces of tape secured the endotracheal tube. A twist of the finger adjusted the I.V. rate. Dr. Billing’s own heart began to slow down. He never showed it, but he always got very tense during the entubation procedure. With the patient paralyzed one has to work fast, and do it right.
With a nod, Dr. Billing indicated that Gloria, D’Mateo could begin the prep of Nancy’s shaved perineum. Meanwhile Dr. Billing began to make himself comfortable for the case. His job was now reduced to close observation of the patient’s vital signs: heart rate and rhythm, blood pressure, and temperature. As long as the patient was paralyzed, he had to compress the ventilating bag, to breathe the patient The succinylcholine would wear off in eight to ten minutes; then the patient could breathe herself, and the anesthesiologist could relax. Nancy’s blood pressure stayed at 105/70. The pulse had steadily fallen from the anxiety state prior to anesthesia to a comfortable seventy-two beats per minute. Dr. Billing was happy, and he looked forward to a coffee break in about forty minutes.
The case went smoothly. Dr. Major did his bimanual examination and asked for some more relaxation. This meant that Nancy’s blood had detoxified the succinylcholine given during the entubation. Dr. Billing was happy to give another 2 cc. He dutifully recorded this in his anesthesia record. The result was immediate, and Dr. Major thanked Dr. Billing and informed the crew that the ovaries felt like little smooth, normal plums. He always said that when he felt normal ovaries. The dilation of the cervix went without a hitch. Nancy had a normally antero-flexed uterus, and the curve on the dilators was a perfect match. A few blood clots were sucked out from the vaginal vault with the suction machine. Dr. Major carefully curetted the inside of the uterus, noting the consistency of the endometrial tissue. As Dr. Major passed the second curette, Dr. Billing noted a slight change in the rhythm of the cardiac monitor. He watched the electronic blip trace across the oscilloscope screen. The pulse fell to about sixty. Instinctively he inflated the blood pressure cuff and listened intently for the familiar far-away deep sound of the blood surging through the collapsed artery. As the air pressure drained off more, he heard the rebound sound indicating the diastolic pressure. The blood pressure was 90/60. This was not terribly low, but it puzzled his analytical brain. Could Nancy be getting some vagal feedback from her uterus, he wondered. He doubted it, but just the same be took the stethoscope from his ears.
“Dr. Major, could you hold on for just a minute? The blood pressure has sagged a little. How much blood loss do you estimate?”
“Couldn’t be more than 500 cc,” said Dr. Major, looking up from between Nancy’s legs.
“That’s funny,” said Dr. Billing, replacing the stethoscope in his ears. He inflated the cuff again. Blood pressure was 90/58. He looked at the monitor: pulse sixty.
“What’s the pressure?” asked Dr. Major.
“Ninety over sixty, with a pulse of sixty,” said Dr. Billing, taking the stethoscope from his ears and rechecking the flow valves on the anesthesia machine.
“What the hell’s wrong with that, for Christ’s sake?” snapped Dr. Major, showing some early surgical irritation.
“Nothing,” agreed Dr. Billing, “but it’s a change. She had been so steady.”
“Well, her color is fantastic. Down here, she’s as red as a cherry,” said Dr. Major, laughing at his own joke. No one else laughed.