What you need to know:
- Patients with phaechromocytoma will produce adrenaline outside of the adrenal glands.
- This means that this adrenaline is unregulated and will be produced inappropriately and in high levels that can be a threat to life.
The good professor methodically scrubbed his hands and arms at the scrubbing area. The sun had just risen and was shining brightly through the high windows in the operating theatre. He had done this countless times over the decades that he did not have to think about it. He was jolly prepared for the day. I was an absolute greenhorn — in my fifth year of medical school — and could not wait for the surgery to commence.
Prof Khwa Otsuya, a cardiothoracic surgeon, was performing this rare surgery for the ninth time. I felt extremely privileged even though I wasn’t going to be scrubbing today. I was working with the anaesthesia team. The surgical team has a long-standing adage, “in the operating room, the surgeon cuts but it is the anaesthesiologist who keeps you alive.” It doesn’t matter how well the surgeon does, if the anaesthesiologist is not at the top of their game, we are all in trouble.
As Prof Khwa scrubbed, he asked me whether I had breakfast. I nodded vigorously and he smiled. I didn’t think much of this question but maybe I should have. By the time he came to the operating table, the patient was already under general anaesthesia and there was a small tray set at the side and a chair for him to sit. He methodically started by inserting the arterial catheter in the patient’s right wrist before he went back to the sink to scrub all over again.
The lead anaesthesiologist had set up a raft of intravenous infusions, boldly labelled with the drugs they contained. Whereas normal surgeries have an anaesthesiologist assisted by a technician, there were two anaesthesiologists, two technicians and myself, as the student on rotation in anaesthesia. The surgical team comprised the good Prof, two other senior surgeons and the student on rotation in surgery. The nursing team was not left behind either, there were five in the room. Clearly this was no regular surgery.
As a student, I was given two infusions to manage, the plain saline fluids and the antihypertensive infusion. I would open up the flow and/or stop it on instruction, based on how the patient’s blood pressure behaved. There were a myriad monitors to guide us on the patient condition throughout the surgery.
Finally, it was time for the surgery to start. Call time was 7am and the surgeon put scalpel to skin. Before I was exposed to surgery, I held the common assumption that surgery meant using a scalpel literary throughout the procedure. Now I know better. That scalpel’s job in many instances ends at opening just the skin!
I would best sum up the surgery as a 14-hour rollercoaster ride. This is the expectation when surgery is carried out for a phaechromocytoma, a rare, non-cancerous tumour made up of cells that produce adrenaline. Adrenaline is our stress hormone, better described as the fight or flight hormone. It is produced naturally in the adrenal glands and its role is to prepare the body to tackle stressful situations.
The release of adrenaline by the adrenal glands results in increased blood pressure, increased pulse rate, increased release of glucose into the bloodstream, increased blood flow to the brain and muscles and increased size of the pupil of the eye. All these effects, in a stressful situation, are to bolster your capacity to deal with the stressor. Hence it is mostly required in small doses and has a very short action span in the body.
Patients with phaechromocytoma will produce adrenaline outside of the adrenal glands. This means that this adrenaline is unregulated and will be produced inappropriately and in high levels that can be a threat to life. Commonly, these patients will keep showing up at the hospital with repeat episodes of extremely high blood pressure that may cause loss of consciousness. Outside of these episodes, the patient may be fully normal.
The tumours are extremely sensitive and easily respond to any disturbance by releasing a fair amount of adrenaline. The surgical manipulation required to access the tumour and to dissect it out of the body becomes a constant trigger to release the adrenaline. The surgical procedure becomes a wild balance between the surgeon very carefully and gently attempting to reach the tumour and excise it while repeatedly stopping to allow for the triggered adrenaline effect to die down.
Every touch would give rise to astronomical blood pressures and pulse rates, requiring medication to bring them down to manageable levels. This is to avoid complications such as stroke or cardiac arrest. The anaesthesiology team is truly put to the test. It was a dance with death!
The excruciatingly slow progress of surgery is the true test of patience for the surgeon. The crazy rise and fall of the patient parameters had our blood pressures rising and crashing in tandem with the patient’s. There was no break. Not to eat, not to the bathroom, not to sit. The Prof kept the tension down by keeping conversation going. He was the only one who appeared at peace. I was awed by his capacity to remain so calm while we were sweating.
Without warning, one of the assisting surgeons stepped back from the table and two steps later, he stumbled over. He was caught by the nurses and carried off to the recovery area. The Prof looked up and dismissed us students to go and eat something. It was when I realized we had been in surgery for 10 straight hours yet it was not over.
Surgery came to an end and the patient was wheeled to the ICU 14 hours later. Prof Khwa finally took off his gloves and sat down. I just had to ask him what constituted his regular breakfast. I was also very clear in my mind that I would never be a cardiothoracic surgeon!
Dr Bosire is an obstetrician/gynaecologist