Bill Hamilton was a bear of a man. Tall and muscular, he cut an imposing figure through the OR hall of UCSF’s Moffitt Hospital. Besides being the former Chair of the Department and the reputed “Mask King,” Dr. Hamilton had also helped develop the modern intensive care unit and had co-authored George Gregory’s landmark NEJM article on the invention of CPAP. Dr. Hamilton also looked like he could have been playing linebacker for the San Francisco 49ers.
As a first-year resident on my Moffitt Hospital rotation, I was getting Ted Eger and Bill Hamilton both in the same month. After Dr. Eger inhalation induction days, I felt ready for the “Mask King.” I could mask!
I had set up anesthesia for the day—one full of gynecology cases, hysteroscopies, D&Cs and a tubal ligation. I checked out the anesthesia circuit and had different sizes of endotracheal tubes, multiple sizes of LMAs, oral and nasal airways, two different laryngoscope blades and handles, two different induction drugs, two different muscle relaxants, and multiple vasoactive agents ready to go. I was learning to be prepared. I was prepared for anything; I had Plan A through E covered. I was prepared for it all.
Dr. Hamilton came in the OR and looked around first at my anesthesia machine top and then at my anesthesia drug cart. He sighed and then wordlessly proceeded to put all my airway equipment and drugs away for the next five minutes, tucking them back into the drawers or under surgical towels. What remained were three syringes: thiopental, succinylcholine, and fentanyl. A lone endotracheal tube remained with a single laryngoscope. A former Army anesthesiologist, Dr. Hamilton wanted it neat and tidy, not the first-year cluttered mess he had walked in on.
“Anesthesia can be pretty simple if you let it be,” Dr. Hamilton said after cleaning up. “You’ll only need these drugs and maybe an endotracheal tube, but your cart was too cluttered.” I stuttered something about plans A through E, but Dr. Hamilton was having none of it. “All you need is this,” he said, gesturing to the anesthesia machine. “And this,” he said, as he held up his giant right hand. Is that a hand or a bear claw? I remember thinking, as he held up his right hand. Dr. Hamilton, aka “the Mask King,” possessed giant hands. Better to mask ventilate with.
My day with Bill Hamilton was unlike any other. True to his reputation, the day was all about masking patients. We would induce with a small dose of thiopental and fentanyl, and I would mask isoflurane the entire case, trying to match the patient’s ventilation. No oral airways, no endotracheal tubes, no ventilator. Six hours of mask ventilation, with three Gyn patients—a hand marathon for any anesthesiologist. One of the strangest days ever and perhaps one of the most impactful.
Mask ventilating a patient for an entire case changed my perspective as an anesthesiologist. I was forced to be close to a patient in unexpected ways. My hands learned the contour of each patient’s jawline. I felt every breath the patient took, as I sat on a stool at the patient’s head. I could not look at the monitors which were behind me, so my hearing became attuned to the sounds of the pulse oximeter and EKG. I could not write on my paper anesthesia record, which Dr. Hamilton did for me as my scribe. My job was to focus on the patient.
“Watch their lips. If their oxygenation drops, you can see it. Everything you need to know is in front of you,” he would whisper to me. “Feel every breath.” Strangely, even with hands hurting throughout the day, I became closely bonded, physically and mentally, with my patient.
My mind wandered a bit during these hours, not on anesthesia records, antibiotics, or emergency drugs, but on the thought that this was an ancient anesthetic that pre-dated the technology of today. No machine, no vital signs, just a couple of drugs, anesthesia gas, and my eyes and hands.
“I’m going to change things up behind you. Tell me if you notice anything,” Dr. Hamilton said sometime in the third case as I mask ventilated the patient. “Just pay really close attention to the patient for the next 10 minutes.” I did as I was told, although my hands were starting to cramp. I tried to remain focused. Nothing changed, the patient breathed as normal, the lip mucosa remained pink.
“What did you change?” I asked after the time ended. Dr. Hamilton just shrugged, “I turned off the oxygen, and you were on room air. Didn’t notice anything different, did you?” I was stunned. We had just done 10 minutes of mask ventilation anesthesia with ROOM AIR.
Dr. Hamilton felt my bottled terror and then intoned some of the greatest words any anesthesiologist could ever hope to learn. “Nobody ever died in the OR from lack of oxygen; they died because of lack of ventilation.” Those words left me stunned. Of course, the biology of our respiration had evolved for room air! As my brain became distracted, Dr. Hamilton admonished me to keep watching the patient. He noticed how tired my hands were becoming. “For the next case (our fourth), let us use an LMA. You can hand ventilate with the LMA.” Thank the gods in heaven, I said in quiet fatigued prayer.
At the end of the day, Dr. Hamilton pulled me aside to review the day. He told me that the point of mask ventilating the whole day was to develop muscle memory in my hands and not to rely on medications and technology. Old school anesthesia. He told me to have better posture—to sit and stand up straight as an anesthesiologist, to have an OR presence. As he left the room, he slapped me on the back with affection. “Keep working hard!” he said encouragingly. I winced with the brute force of the playful back slap. Bill Hamilton was a bear of a man.
As I sat alone with my thoughts in the OR, I looked down at my two hands. They were both throbbing in pain and both fixed in the shape of an “L”. I held my two hands up. They were frozen in mask position, both forming symmetrical “L’s.” Are these hands or are they claws? As I made my way back to the resident lounge, hands still hurting, a few other residents were still there.
“How did your day go with Hamilton?” asked one with a cynical grin. I just held up my two cramped hands with a tired smile. And wordlessly, the other residents in the lounge held up their two hands into symmetrical “L’s,” almost in a mocking salute. They had been through Hamilton’s tutelage as well. And we all air masked-ventilated together, our hands transformed into pinching Bill Hamilton lobster claws. And we all just laughed without reservation.
Next –The Legacy of Iowa Nice (Conclusion)
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 CSAOF and was a resident anesthesiologist at the 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. He is a current Delegate for the Hospital-Based Practice Forum at the California Medical Association and District 3 for the CSA.