Part I - Ted Eger’s Rainbow
“Hi there, you must be Dr. Chow,” said a voice behind me. It was a gentle but firm voice.
I was sitting on a bench the UCSF Moffitt Hospital OR locker room changing into my street clothes. It had been a long day, and honestly it had been a tough start to residency. I was just in my second month and was wondering if this specialty was right for me.
I turned around to see the voice. I had been caught by surprise since few people knew me anywhere in the hospital. I was surprised to hear my name at all.
Standing a few feet behind me was a thin, spectacled man, wearing a lab coat, grinning radiantly at me. “This man has such a giant head,” was my very first impression of the man before me. “Hi my name is Ted,” said the man as he extended his hand for a handshake greeting, “we are working together tomorrow.”
Before I headed home, I stopped by the Moffitt OR anesthesia resident lounge. A few of my classmates were still milling around even in the late afternoon talking about their OR case assignments for the next day.
“Hey Harrison,” asked a classmate, “who are you working with tomorrow?”
“Somebody called Ted, Ted Eger, does anybody know about him?” I asked quizzically.
For a few seconds, the anesthesia resident lounge got quiet. What did I say?
“You really don’t know who Ted Eger is?” cackled the classmate. “Get ready for the Ted Eger Rainbow.”
“What’s a Ted Eger Rainbow?” I asked, still confused and disoriented.
The anesthesia resident lounge just all started laughing. “Dr. Eger is going to make you mask induce anesthesia with the gases either developed or researched from his lab.”
“Which ones are those?”
“All of them,” I was told: Light blue Enflurane, Dark Blue Desflurane, Purple Isoflurane, Orange Halothane and Yellow for Sevoflurane. Nobody had seen the Methoxyflurane dispenser which supposedly was red. But all of these were Dr. Eger’s lab concoctions developed from his patents.
The next day I was apprehensive. I had never done a mask induction before. As I changed in the Moffitt locker room, I kept worrying about how to do this, how to do a mask induction? “Good morning Dr. Chow,” a familiar warm voice again had snuck up on me again. I turned around to see a smiling Ted Eger. The great Dr. Eger then sat next to me on the OR bench as casually as if he was an old friend. “Do you want hear a story about those booties?” said the father of volatile gas anesthesia, gently touching my shoe booties. I looked at my watch. I was worried about the OR starting on time. Dr. Eger saw my concern and just said dismissively, “the OR can wait.”
Dr. Eger then spent the next 20 minutes talking about the history of the OR shoe bootie and volatile anesthesia. He described how he and others were trying to chemically alter the highly flammable ether to the different variations of anesthetic gases, but fires kept breaking out. The cause was electrostatic sparks from shoes worn by anesthesiologists and others. These fires had broken out in ORs and in his labs.
“Shoe booties weren’t created to keep surgeon shoes clean; they were created to stop anesthesiologists from catching fire,” he summarized in the locker room lecture. “Everybody thinks I created these gases for their clinical properties but first they had to be non-flammable, always safety first.” He then went into a brief history of the flammability of anesthetic gases tested in his lab, from Ether (a bomb waiting to happen) to Desflurane (will not burn). “There are better anesthetic gases in my lab that are just too dangerous for the OR,” he concluded. “Shall we do that hernia now?”
Our hernia was already 30 minutes late, but Dr. Eger did not seem to care and neither did the OR. The hernia that was scheduled was going to be laparoscopic. In 1995, laparoscopy was just becoming mainstream in general surgery, and apparently this was one of the first laparoscopic hernia repairs at Moffitt. The OR was a ball of confusion with bulky TV monitors, unfamiliar surgical equipment, and crowded with more surgical personnel than needed.
As we entered the OR it occurred to me that Dr. Eger had known the case would be delayed, which is why he had been so casual with his locker room lecture. Finally, we had a patient, a healthy man getting a new form of hernia repair. The patient could not have been prouder to be one of the first. What he did not know was that he was going to get the blue part of the Ted Eger Rainbow. Yes, the patient was going to have a desflurane mask induction. Yes, you read that right. Desflurane.
Dr. Eger had flooded the circuit with Desflurane. He had gone beyond the safety click of the maximum dose on the dispenser to generate some kind of super dose of Des. The pungency was even irritating to me, but I sat down on a stool over the patient’s head and placed the Des-reeking mask over the patient’s nose and face to form the customary seal. The thinking was that the concentrated Des rush would overcome airway reflexes.
The patient who had been beaming the whole time, proud of being part of the early laparoscopy, was suddenly overcome with terror with his first breath of the super-concentrated Des. I could see his eyes looking up in fear, and then his eyes rolled back as the anesthesia began to enter the brain in mere seconds. “Wow that was fast,” I thought. “Desflurane is as fast as thiopental,” whispered Dr. Eger into my ear as I masked the unconscious patient. “But it’s not over yet Dr. Chow,” the voice warned softly.
Almost on cue, the patient started to cough, and sputum started to flow out the side of the mask as he started to buck. “Don’t worry about it,” said the voice as Dr. Eger suctioned and dabbed dry the secretions. “The patient is having laryngospasm, the Des will overpower it, the vocal cords will relax, just keep the seal.” After about a minute of this, the patient became still. I could ventilate again!
“Was this over yet?” I thought to myself, reaching over with one and briefly to wipe sweat off my brow. “Watch out Dr. Chow, here comes stage II anesthesia,” whispered Dr. Eger into my ear, seemingly reading my thoughts.
I looked up briefly at the surgical team who had been excited about their new high-tech procedure. They now looked on with frustration. Almost on cue, the patient started to move again, like a puppet on strings having a seizure. The legs and the arms first jerked, the body wiggled, and then the patient froze into a posture like having a grand mal seizure. I maintained the mask, but I was worried how this must have appeared to the concerned onlookers.
“Don’t worry,” whispered the calm voice behind me as the patient than slumped. “Can we intubate yet?” I worriedly asked as I held the seal. I wanted to reach for the thiopental and sux, to end the unorthodox anesthesia – the syringes were in sight just a few feet away from me.
“Not yet,” said the voice, “some more coughing is coming just wait, this might take some time.”
“Is this necessary?” asked an unfamiliar voice. As predicted the patient started coughing. A deep lung-based asthmatic cough this time, like the lungs were trying to expel the invading Des gas. I held the mask seal as the patient coughed, but these became gentler each time. I looked up briefly to see where that voice was coming from.
During what seemed our eternal mask induction, the surgical fellow had been consulted, “Can you just intubate the patient already?” Ted Eger wordlessly lowered his head and glared at the fellow. As I absorbed the scene, a mask Desflurane induction with a constantly bucking and jerking patient, I could feel the air vibrate with friction as Dr. Eger laid his eyes on the poor fellow. Was Dr. Eger telekinetic?
“Dr. Chow, I think the patient is ready to intubate,” said the calm voice behind me ignoring the fellow. I reached now for the thiopental and sux syringes. “You won’t be needing those,” he said with a dismissive tone, “Who needs muscle relaxants anyway?”
As we intubated smoothly sans muscle relaxants, the surgeon attending came into the room. “Ted, I’m sorry for my fellow," said the surgical attending admonishing his surgical fellow, “he’s new here, still figuring things out.” I sighed in relief; mere mortals do not question academic demi-gods. Dr. Eger nodded wordlessly while taking off his mask. Underneath was a broad smile; he had been completely unfazed by it all. I, however, was already drenched in sweat.
“You see Dr. Chow, you can mask induce with Desflurane after all,” he said cheerfully. What a smile Dr. Eger had! “Let’s do halothane next,” he said as he turned to leave the room. My heart sunk a bit, and a familiar dread came back. I had just started on the blue of Ted Eger’s rainbow. What was coming next?
Be on the lookout for Part II - The Bill Hamilton Lobster Claw
More information about the CSA Committee on the History of Anesthesia can be found here: http://csahq.org/about-us/history-of-anesthesia
Harrison Chow, M.D., M.S. is a frequent contributor to the CSAOF and was a resident anesthesiologist at University of California-San Francisco from 1995-1998. Currently he is an Associate Professor of Clinical Anesthesia, Stanford Medical School and a former Department of Anesthesia Chair of Good Samaritan Hospital and is a current Delegate for the Hospital-Based Practice Forum at the California Medical Association and District 3 for the CSA.