ver the past couple of months, I have had the opportunity to assist in the care of the Carlsen twins, a set of conjoined twins joined at the chest and abdomen, sharing a liver biliary tree, proximal small bowel and pericardium. The “twofer,” or two for the price of one, was Isabelle and Abigail, two beautiful 5-month-old infants brought to Mayo Clinic from Fargo, North Dakota, where mom is a nurse and dad is a highway engineer.

The girls have now spent nearly three months at the Mayo Clinic. During that time, they have undergone three procedures requiring anesthesia, the last of which being the separation itself. The process of caring for a pair of conjoined twins was a fascinating one involving a great deal of preparation, organization and teamwork. The first two procedures, placement of tissue expanders and endoscopy, were, in essence, dry runs for the main event — the separation. Throughout the process of preparation, my colleagues and I worked in close cooperation with colleagues from pediatrics, pediatric surgery, pediatric cardiac surgery and radiology, to name just a few. We evaluated the children prior to each of the anesthetics, provided postoperative pain consultation, worked with our surgical colleagues to organize the operative environment and provided intraoperative care and intensive care until well after the girls were extubated.

The Procedure
The day of the separation commenced at 0530. Abby and Belle entered the operating room (O.R.) with mom and dad at 0630. The anesthetic was a complicated process that began with a simultaneous inhalation induction followed by the difficult task of gaining adequate intravenous access in infants lying on their sides closely facing one another. In the end, after approximately 13 hours in the O.R., the separation went far more smoothly than any of us predicted. The hepatic and biliary anatomy was very complex and presented a significant challenge to the surgical team. Although we expected the division of the liver to be difficult and bloody, the blood loss was modest. Belle’s heart was positioned partially outside her chest, and finding room to allow closure was the final challenge of a very challenging operative day.

Leaving the O.R. late that evening, I had at least some expectation that I may be able to extubate one or both of the twins the following morning. My optimism was clearly misplaced, because closure of the chest and abdomen restricted chest wall movement for both girls, necessitating the use of high pulmonary inflating pressures and in turn requiring significant additional fluids to support right atrial filling pressure. Extubation had to wait until edema resolved and pulmonary compliance improved at about 48 hours after the procedure. Both were transitioned to nasal CPAP and then to blow-by oxygen over the next day. Care was transferred to our pediatric colleagues on the fourth postoperative day. A pediatric anesthesiologist/intensivist was continuously at the bedside from induction throughout the procedure most of the following night and much of the following day. We were certainly there for all of the critical portions of the procedure.

Media Scrutiny
Although this case represented a unique set of challenges, our anesthesia team members were well-equipped to deal with them. Along with these girls and their parents came, however, a virtual tsunami of media interest and coverage. This coverage, which began when the family chose to share their girls’ story publicly and before they arrived at Mayo, reflected the curiosity and fascination of the American public with the girls and their family. Consequently, caring for Abby and Belle presented the challenge not only of providing the best in perioperative care but doing so under the microscope of intense public interest and scrutiny. For my colleagues and me, there was much to be learned from the care of the girls, not the least of which was how to function under the “bright lights.”

Media attention is a relatively rare event for us. As anesthesiologists we tend to toil in the shadows, preferring to remain in the background, quietly leading the way toward safer hospital care. We pursue this end at the bedside, in the boardroom, in the laboratory and through the work of organizations like ASA and the Society for Pediatric Anesthesia.

Anesthesiologists are devoted to providing the best care possible with the realization, however, that when the bright lights shine on us, it is often because the outcome was less than hoped for. Recently the ASA leadership has found it necessary to respond to the portrayal of an anesthesiologist on the Sunday evening drama “Grey’s Anatomy.” In a recent episode, an anesthesiologist is portrayed as a coward, caring more for himself than his patient.

Before “Grey’s Anatomy,” the story du jour was intraoperative recall. Much of that coverage suggested that anesthesiologists were not doing enough do prevent this new “epidemic.” The formula (“CBS Evening News,” the “Today” show, etc.) for this story ran as follows: A patient is interviewed by a very serious, sympathetic and sincere journalist. The patient describes a truly horrible experience of intraoperative recall and is immediately followed by an industry-supported spokesman whose message is, “if only anesthesiologists would use this widely available device, all this would never have happened.” Once again we anesthesiologists found ourselves in the media spotlight on the defensive.

What is the common thread that connects “Grey’s Anatomy,” the “CBS Evening News” and the “Today” show to two little girls named Abby and Belle? Obviously it is medicine and its relationship to the media — more specifically the image and portrayal of anesthesiologists by the news media and Hollywood.

On the day of the separation, after the girls were safely induced, airways secure and vascular access obtained (much of the process videotaped), I took time for a quick cup of coffee and found myself expressing to one of my colleagues not only a sense of relief and satisfaction that we had navigated a difficult course but also some frustration with the media involvement. I described to her that, although the media were expertly (a credit to our communications department) managed and were quite polite, compliant and respectful, the nearly constant scrutiny was adding a great deal of stress and complexity to a situation that was already complicated and difficult.

Stepping Into the Spotlight
In our conversation, I mentioned that I was seriously considering skipping the evening news conference that was to follow the surgery. Although I am not sure what I expected her response to be, I certainly did not expect that she would quietly suggest that I should make a point to participate. She said to participate was, in a way, a duty — a duty not only to the team of the anesthesiologists and nurse anesthetists who had worked so hard to care for the twins but also to colleagues around the country.

When a medical procedure requiring anesthesia makes news, rarely are anesthesiologists anywhere to be seen. The spotlight shines brightly on a surgeon who may mention the presence or assistance of an anesthesiologist in the care of the patient in question. Our collective reluctance to step forward perpetuates the popular ignorance of the critical role anesthesiologists play in the perioperative care of children and adults. We are fortunate that in this case the surgical team, led by my colleague and friend Chris Moir, M.D., was determined to ensure that the contributions of all those who participated were recognized.
So with the advice of my colleague, Denise J. Wedel, M.D., in mind, I determined that I would make a point of attending the news conference and use the opportunity to highlight the important role of anesthesiologists in the care of these children — and by extension, the care of all patients requiring surgical procedures.

It is my sincere hope that we succeeded, first, in providing the best perioperative care to Abby and Belle and, second, in representing all those who provide anesthesia care in the most positive of bright lights.

Randall P. Flick, M.D., is Head of the Section of Pediatric Anesthesiology, Mayo Clinic, Rochester, Minnesota.