(++++) IN THE BORDERLANDS

Saving Grace: What Patients Teach Their Doctors about Life, Death, and the Balance in Between. By David D. Alfery, M.D. Wipf and Stock. $21.

     Most people are no more aware of the guts of medical practice than they are aware of their own internal digestive tract. That is probably just as well: in neither case is the subject pretty, and it is probably best simply to accept the topic as is and go on with one’s everyday focuses in life with a degree of abandon and willful ignorance. That is, until something goes wrong. When it does, to the point of requiring surgical intervention, we put our lives quite literally in the hands of surgeons and, to an extent that most people do not think about, in those of anesthesiologists.

     Patients rarely meet those who administer anesthesia until very shortly before surgery, but it is those doctors (and CRNAs, Certified Registered Nurse Anesthetists, and in some cases CAAs, Certified Anesthesia Assistants) who must carefully keep a patient balanced on a knife’s edge (or scalpel’s edge) between wakefulness and enormous pain on the one side, and death on the other. This is a twilight world, a life-and-death border that modern anesthesia straddles comfortably when all goes well, far less comfortably when anything goes wrong, and always with a certain awareness that the practitioners of anesthesia are not entirely sure of why it works. “I sometimes wonder if patients would be so trusting if they knew how much we still don’t know about general anesthesia,” writes anesthesiologist David D. Alfery, who has boiled down the lessons of his 36-year career into 15 single-word-titled chapters (“Respect,” “Dignity,” “Fragility,” “Unfathomable,” etc., although “Allegiance” is repeatedly and embarrassingly misspelled) that collectively bring readers behind the curtain of mystery where so much of the enormous complexity of modern medicine is concealed.

     Saving Grace is, for example, a place to learn about the innocuously named “quiet rooms,” which “are found throughout a hospital, in every hospital, and one is always adjacent to an ICU. Nothing good happens in them. …Lighting is muted. They are invariably small, cheerless, non-descript spaces usually consisting of a few chairs, a table and lamp, and perhaps a sofa, where families are brought to learn in private that the worst of their fears has been realized.”

     The book is also a place to find out how doctors used to estimate the likely survival of burn victims: “We calculated expected patient mortality by adding the percentage of body surface with third degree burns to the patient’s age.”

     And it is a place to learn just who all those people in the operating room are – for patients awake enough to see the team together. There may be one surgeon and sometimes a second, “but in most cases a specially trained surgical assistant was present to help.” There is a “surgical scrub nurse, the person who would hand instruments to [the surgeon] and who’d take them back after they’d been used...[and] would load sutures, hand [the surgeon] a suction catheter when needed, and provide anything else that was required to be sterile.” There is also “a circulating nurse, whose job was to ‘circulate’ around the room, open requested sterile equipment for the scrub nurse, document what was going on, run to the blood bank if needed, send blood samples for laboratory work, update the patient’s family on how surgery was progressing, and so forth.” And there is, of course, the person administering anesthesia, keeping the patient delicately suspended between this world and the next.

     Crucially – and this was not always the case – in surgery today, “at any time, any person present in the OR has the authority to stop an operation from proceeding if they feel an unrecognized danger is present, until that danger is addressed.”

     There are dangers aplenty detailed in Saving Grace, as the book explores the entire range of emotions that patients, families and medical personnel alike experience in cases of serious, often life-threatening and sometimes life-ending circumstances. The “families” element is particularly moving and important, given Dr. Alfery’s realization that pain relief for a patient in extremis is less for the patient than for family members enduring the observation of what is going on: “If you depress consciousness to the point where a patient is not aware of anything around them, where they can no longer respond to the voice of a loved one because they are too asleep to hear it, their body still responds to the pain. It does so by writhing back and forth or by moaning. Those are elemental reactions that a patient is unaware of, just as one is unaware of turning over in bed when asleep or what goes on under anesthesia. The moaning and writhing are nevertheless agonizing for a family to witness.” And this means that if anesthesia or pain-relief medicine, or both, can be used to suppress the outward signs of a pain that the patient is not actually aware of feeling, then the pain that the family is feeling can be alleviated.

     This holistic approach to medicine leads naturally into the elements of Saving Grace dealing with Dr. Alfery’s journey of faith, which occurs alongside and within his growing medical expertise. The religious elements of the book are its most tepid and least successful, but are inevitable in a work brought out by a religious publisher such as Wipf and Stock. It takes little imagination for anyone who has ever had any contact with severe disease and the people who treat it to understand that there is a spiritual dimension to medicine, a whole set of circumstances unexplainable on any currently known or understood scientific basis. The idea that doctors do their work with the highest scientific attentiveness while still acknowledging that some of what happens to patients is beyond their ken is scarcely surprising; the best doctors are consistently humbled by the realization of everything that they do not know. Nevertheless, it is not the faith-focused elements of Dr. Alfery’s book that make it compulsively readable and consistently revelatory. It is the behind-the-scenes information on modern medicine and the place of anesthesiology within it that makes Saving Grace such an impressive achievement.

     For those used to endless discussions about the impersonal elements of medicine today – at least medicine in developed countries, whose contrast with less-developed ones is made clear when Dr. Alfery writes about his time doing medical mission work in Romania – it is salutary to read here, “Don’t ever think your doctors, your nurses, your aides, and anyone else involved in patient care doesn’t feel the same emotions in these horrible situations that you do. We are all part of the same devastating humanity.” Think of that comment as a counterbalance to all the more-often-written complaints about impersonality, limits on time with patients, insurance disputes, deductibles and co-pays, the unaffordability of sophisticated medicines, and all the rest.

     Some years ago, when there were fewer anti-cancer drugs than there are today and meticulous targeting of the medicines was far less possible, oncologists used to say that the objective of the dosage was to measure enough medicine to kill the patient – and then to back off just a little bit. In some ways, there used to be a similar “almost over the life-and-death border but not quite” approach to anesthesia. But if the cruder drugs and methods of the past have now been supplanted by more-precise anesthetics and much-more-precise methods of administering them, there remains the pesky fundamental fact that nobody really knows just how and why general anesthesia works. It is necessary for patients – and doctors – to take its effectiveness on faith. And that is, in its own way, as much a testament to the spirituality that remains in medicine and science as any overt discussion of personal conversion and belief.