There were a lot of unsung heroes at George Washington University Medical Center that day in March when a wounded president, his press secretary and a Secret Service agent were brought in, but chief among them says Dr. Eli M. Brown, were the anesthesiologists.
"Yes," affirms hospital spokesman Dennis O'Leary, "they played a very central role -- and with a low profile."
"Yes," says Dr. Charles Coakley, chief of the GW anesthesiology department, "We did kind of feel left out of this. . . . I was pretty proud of my group. . . ."
For one thing, both the emergency room and the intensive care unit at GW are under the anesthesiology department.
Anesthesiologists are physicians, of course, but they are much more than the stereotypical image of the person who plunks the masks over the patient's face.
For example, Coakley credits Dr. Judy Johnson, one of his residents anesthesiologists, for the quick and efficient emergency action which, he says, enhanced Jim Brady's prognosis. She administered specific drugs and therapies at once to inhibit brain swelling, a complication which could have doomed the president's grievously wounded press secretary.
Dr. Brown, president of the American Society of Anesthesiologists, worries that his colleagues are under-appreciated. Not just his heroic colleagues at GW, but members of the medical discipline per se.
It is, after all, mainly because of anesthesiologists that patients are admitted to hospitals at least a day before an operation, even relatively minor elective surgery.
One of the reasons is to make certain the patient arrives in the operating room with an empty stomach. (Because of the usual procedure involved in putting a patient to sleep, there may be a risk of vomiting. If food is present, there is a danger of choking or of aspirating pieces of food which could lead to lung abcesses or even some types of pneumonia.)
The other reason is the all-important patient-anesthesiologist interview to determine which anesthetics will be used -- according to the type of surgery, how long it may take, allergies of the patient, whether he has a cold or is a smoker.
Emergencies, of course, are something else. And the president and his group had just come from lunch. . . .
"That was not," says O'Leary, "an anesthesiologist's dream."
What they did, says Coakley, was use a "crash technique," a combination of anesthetic agents designed to get the patient under as quickly and smoothly as possible, and to finesse the problem of food being present. (This becomes a problem again as the patient awakens, again requiring specialized skills in which anesthesiologists are trained.)
The president, says Coakley, was not pre-medicated when he was brought into the operating room and was actually feeling better than when he'd first come in. The collapsed lung, the immediate source of his breathing problems, had been reinflated. Also, he was receiving blood.
"He really made those wisecracks about hoping we were all Republicans," Coakley confirmes, and "we almost couldn't believe it, but he did write those notes as he was waking up, including the ones with that W.C. Fields line saying he'd rather be in Philadelphia."
"I don't know what happened to the notes," said Coakley rather wistfully. "We don't have them. They just disappeared."
The president, said Coakley, told the doctors in the operating room that he was wearing one contact lens. "We thought he was confused," admitted Coakley, "and we checked with an ophthalmologist who said he never heard of such a thing, so we put a dye in the other eye just to make sure. But the president was right."
(Reagan uses a relatively new technique -- monovision -- in which one or two soft contact lenses may be uses.)
Coakley said that the president was first anesthetized with a small amount of Pentothal -- a common practice -- along with a skeletal muscle relaxant that is related to curare. The last was to permit insertion of the endotracheal tube. He was maintained at a light level with ethrane and oxygen, and was awake at the end of the procedure.
Brady also was given Pentothal initially -- it is very short-acting -- and was maintained during the long procedure on a synthetic narcotic and nitrous oxide. Both operations were such that only light anesthesia was required. (There is no sensation of pain in the brain itself, and, said Coakley, "Once you're inside the rib cage," it is not some much of a problem either.)
Eli Brown, who leads the anethesiology department at Wayne State Medical School in Detroit, was here recently for the annual meeting of the anesthesiology society. He heard some of the details of the shooting emergency from colleagues at GW. It was, he notes, the quantum leaps in anesthesia, mostly since World War II, that now make long hours of intricate surgery possible.
It used to be, he says, that "we might say a patient was not suitable for surgery. We don't say that any more. . . ." The combination of new agents and new monitoring equipment -- brain waves during brain surgery, for example -- has enabled the development of intricate surgical procedures unthought of as a few as 30 years ago. And enabled a team to keep Jim Brady's condition stable throughout that 7-hour surgery when his life was truly held in the balance.
"He really did," conceded Coakley, "looks pretty hopeless."
Coakley himself, his principal assistant away on vacation, took on all the coordinating: assigning operating rooms, finding staff, and making sure the FBI and the Secret Service were satisfied with security. ("I don't know which," he said, "they were in greens and they all look alike. . . .")
Happily, a day in the life of your friendly neighborhood anesthesiologist is not usually so harried.
But, notes Dr. Brown, it sometimes takes kind of situation to dramatize the importance of the field.