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Delicate Dozens. With their own adaptation of Dr. Keown's technique, surgical teams at the University of Illinois hospitals have performed 200 operations on the mitral valve without a single death in the operating room (and few deaths afterward). Dr. Sadove reported. Then he spelled out the dozens of delicate steps which the anesthesiologist takes in each such case. The key steps give a good idea of how far anesthesiology has advanced beyond the mask-and-needle stage.
The patient is given barbiturates the night before the operation. In the morning, he first gets meperidine and atropine. In the operating room, needles are placed in the veins, and glucose solution is given (if the heart is especially irritable, procaine as well). Anesthesia proper begins with injections of thiopental and a muscle relaxant of the curare family;* at the same time, oxygen is given by mask. A tube is slipped down the patient's throat, into his windpipe, and he gets his oxygen that way while respiration, pulse and circulation are carefully checked.
Ether is put through the tube to produce deep anesthesia. (Oxygen is still being given.) If the pulse rate drops below 60, the anesthesiologist injects atropine. Procaine is injected into the rib cage and around the heart, and, finally, as the surgeon lays the heart bare, into the heart itself. Only then is the actual operation of widening the valve performed. The anesthesiologist injects lidocaine to block the nerves of the rib cage. As the wound is being closed, he twirls the knobs on the anesthesia machine to give a mixture of nitrous oxide and oxygen. The patient's bed is brought to the operating room, so that he can continue to receive oxygen and intravenous infusions while on his way to the recovery room. To relieve pain after he regains consciousness, he gets meperidine. (But not enough to relieve all pain because, says Dr. Sadove. that would also eliminate the cough reflex, "the watchdog and clean-up man of the chest.") Oxygen is usually discontinued within a couple of days. With that, the anesthesiologist's task is about done.
Small-Arms Fire. Few operations present so great a challenge as those inside the heart. But, in Dr. Sadove's view, the distinction between major and minor surgery disappears when anesthesia is employed, because anesthetics are such powerful and dangerous substances that their every use is a major medical event. That is why the anesthesiologist is called in on the case early, perhaps to help the internist and surgeon decide whether an operation is feasible. That is why, during the operation, the anesthesiologist is responsible for the patient's general welfare, beyond the immediate area where the surgeon is working—and if he says so, the surgeon must stop.
The greatest problems of heart surgery have cemented the relationship between surgeons and anesthesiologists so that now they tend to work more closely in many other types of cases. Dr. Sadove, who spent four wartime years in U.S. Army hospitals in England, likes to use a military metaphor: "The small-arms fire of the anesthesiologist joins the spy system of the lab to back up the surgeon's big artillery in a coordinated attack to conquer disease."