Ketamine is a strange strange drug…

I saw my first ever Ketamine induction yesterday.

It was for a 6 year old boy undergoing bilateral medial rectus botox injections. Apparently, other general anaesthetic agents attenuate the electromyograph signals needed to locate the extraocular muscles too much, and thus render them unsuitable for this procedure.

The boy was shown a little toy snake as a form of distraction whilst I cannulated him.

Then, the ketamine went in.

His eyes remained open. He continued to blink despite looking a little blank. He continued to breathe. He also continued to move his arms about.

Somehow, I don’t know how, my consultant was able to tell that the child was “ready.” She was able to tell that he had been anaesthetised despite him still looking completely awake.

The procedure took all of 5 minutes. We gave him a small dose of midazolam at the end to “dumb down” any emergence phenomena that may subsequently manifest. Then, we transferred him to the recovery area. We shut the doors, turned down the lights, and kept the area as quiet as possible.

The little boy continued to look around whilst in recovery, occasionally picking at his cannula. Then, he started calling out “snake! snake!” He was very obviously having visual hallucinations of the little snake we (erroneously) showed him before his anaesthetic. He started lifting up his covers, and picking up the snake which seemed to have slithered onto his body. The boy did that repeatedly for a good half an hour. Occasionally he would try and get rid of the snake from his body. Other times, he would lean over the bed rails saying “where has the snake gone?” Throughout this entire time, we just watched him deal with his hallucinations. After all, the teaching is not to disturb the child or engage with them as it worsens their nightmares. But what an awful experience it must have been for him!

I wondered how we would know that the child has recovered from his emergence delirium. My boss said that you would just know, because they will start speaking to you properly. True enough, as though someone had flicked a switch, the little boy suddenly came to and asked “When is the botox going to be done? Where is my daddy?” It was then that our recovery nurse finally said her first words to him “it has already been done,” and he cheered.

Seeing as he had finally recovered from the ketamine, the recovery nurse wanted to give him a sticker for his “bravery.” The boy claimed that he did not really like spiderman. “What do you like then?” she asked.

“Snakes” he answered.

It’s disconcerting when unexpected emotions creep up on you…

I was chatting to one of my juniors whilst at work the other day. We were talking about the horrific situations within which we often find ourselves stuck in in our line of work, and how we have all learnt to cope with the physical and emotional toll these take on us. Yet, no matter how hard we try to forget and move on, there are always certain patients who seem to stick in our minds for a very long time…

I was telling her about the story of a 21 year old boy called Michael whom I looked after as a junior doctor 4 years ago.

Michael was a patient on the haematology ward that I worked on as a F2 doctor. He suffered from acute myeloid leukaemia and had been in the hospital for a number of months receiving chemotherapy. As he was one of our long-stay patients, I had gotten to know him fairly well and had taken it upon myself to take ownership of his care and well-being in the hospital.

I remember seeing him on a Friday ward round (my own, as the consultant did not round on a Friday and the registrar wasn’t about in the morning). Michael was semi-asleep, hiding under the covers when I checked on him. However, he claimed that he felt good and had no physical complaints at all. His vital signs and bloods were all stable too.  Michael then let on that he was desperate to be “released” on home leave that weekend. Seeing as there was nothing really to stop me for letting him go home for a couple of days, and on agreement with my registrar later in the day, we said goodbye to Michael that afternoon and “see you back on Monday!”

Monday came around soon enough, and Michael came back onto the ward that morning looking dreadful. He had become really unwell over the weekend. The diagnosis? Pseudomembranous colitis. In fact, Michael had become so poorly that he was promptly admitted to the intensive care unit. Whilst he was in ITU, he was aggressively resuscitated, started on inotropes, and provided with a course of strong antibiotics. He did not respond to the treatment at all. In fact, he responded so poorly that it was felt that there was not much more we could do to “cure” him. “Flogging” his body with further aggressive and invasive treatment was not going to do him any favours… it was only delaying the inevitable, and denying him the option of a good, dignified death. The only choice hereon was withdrawal and palliation.

Now, despite being so terribly ill, Michael remained compos mentis throughout. He decided that he did not want to remain in the ITU, but instead chose to be transferred back to the haematology ward to die. He wanted to be in familiar surroundings, with people whom he knew loved him and had cared for him these past few months. During the time when the ward was arranging a side room for him to return to, Michael even wrote a goodbye and thank you note to the staff on the ward. It was heart-breaking to read.

The atmosphere on our ward was sombre on the day Michael came back to us. There was a dark cloud looming over all of us all day, and a heaviness in our hearts that weighed us all down. He had come back to the ward with a syringe of noradrenaline to keep him alive, and we all spent the day agonising over the count-down to a time when the noradrenaline would run out– the time when death would be pronounced over our dear patient and friend. Throughout the day, the staff on the ward took it in turns to go and say goodbye to Michael (who was still fully awake and aware). No one came out of his side room with dry eyes. Even the counsellor was found sobbing uncontrollably after going in to see Michael.

As for me? I did not go and say goodbye to Michael that day. I was awash with emotions that I knew I would never be able to take control of if I even began to lose it. I had 2 patients in 2 side rooms next to each other dying on the ward. The nurses were disraught. Yet there are still so many other patients who needed looking after. I was sad but had to remain in control. I pressed on with a brave face and a constant need to dab my eyes with my shirt or a tissue all day.

I wondered what it must have been like for Michael to be inside that side room waiting for the Grim Reaper. What could possibly be going on inside his head as he looked at the syringe’s plunger slowly inching its way towards the nozzle, knowing that when the 2 parts kissed, the candle of his life will be snubbed out? I wonder how difficult it must have been to say goodbye forever to his girlfriend and his family? How can anyone be ready to leave at age 21? What about marriage, children, career, dreams, retirement? How can one die in peace when there are still so many regrets in life? How did Michael feel witnessing everyone crying over his soon-to-be passing? How did he control his feelings in the midst of the chaos of emotions that was poured out onto him?

Michael died at approximately 7pm that awful day.

As I was recounting this story to my colleague that day, I found my eyes welling up in tears yet again. The little pearl drops of fluid rolling down my cheeks completely took me by surprise. It has been 4 years since Michael died after all. After such a long period of time, I had expected the rawness of witnessing such suffering to have somewhat healed already.

Nevertheless, like I said, some patients just seem to stick in our memories for a long long time. Their story becomes a part of ours, and I guess their memory lives on.

Michael, you are not forgotten by this stranger.