lessons learned

The Patient Who Fought Back

How do you sedate a drug dealer?

JACK RUNNINGER, O.D.

Another weird "patient communication" case happened to ophthalmologist Dr. David Meltzer, as reported in Dr. Ben Milder's book on the history of Washington University Department of Ophthalmology and Visual Sciences. In the case, which follows, Dr. Meltzer begins his residency with a drug dealer patient whose left eye has suffered a bullet wound, courtesy of a rival gang, which requires enucleation under local anasthesia.

How much?

Dr. Palmberg nor I were in a state of intimate familiarity with the drug culture. He was at pains not to over-medicate our 220 pound, six-foot-three, very muscular, multiple-head-wound, drug-dealer patient. So, the patient was given 50 mg of Demerol shortly before being taken to the operating room.

It was decided that I, the first-year resident, should begin my surgical career by performing the peritomy, while the actual enucleation would be done by Dr. Escapini. Xylocaine was carefully injected in the orbit and immediately drained out, the patient's hepatic enzymes were tantalized by their apertif of Demerol, and we were ready. I took up scissors and forceps. I tentatively grasped the conjunctiva. The patient moved violently and yelled.

More

Do not worry," said Escapini. "We will give a supplemental." More Xylocaine was injected. Even more tentatively, I regrasped the conjunctiva. The patient screamed louder.

Escapini injected more Xylocaine. "You," he said pointedly to me, "will never become an eye surgeon unless you learn to cut. You have to cut quick."

I grasped the conjunctiva and there was another scream. After some reflection on why I had taken this road in my career, I handed the instruments to Escapini, saying that this did not seem to be a case ideally suited to a first-year resident.

With no effort to hide his considerable scorn, Escapini took the instruments as Heifetz might take up his bow and violin. "I will show you how to cut," he said.

The virtuoso

He stood over the patient—poised, weight evenly balanced. He brought the instruments near the eye, but for a moment did not touch. Then with blinding speed (the candid reader will understand that no unfortunate pun is intended) he made an extraordinary movement which opened a peritomy of at least 270 degrees.

Unfortunately, the stroke was not instantly fatal. The patient gave a roar, got off the table, made scurrilous allegations about Escapini's relationship with his family, and signified his intention to alter Escapini's person so as to remove from him all hope of progeny.

Elsie Meyers, head of ophthalmological anesthesia, was urgently called. When she appeared, she turned on the anesthesia machine, and chased the patient around the room with a hose emitting halothane, and herself eminating soothing remarks. "There, there, you really don't want to do that to the doctor. Doesn't this smell nice, just like new-mown hay..… You are going to sleep…No, no, you do not want to do that to the doctor."

Both the halothane and the soothing remarks were distributed widely in the operating room. When I awoke, the case was done, patient again had survived. OM

Editor's note: Dr. Runninger has received the permission of Dr. Meltzer to reprint this excerpt.