Anesthesiologist saves a life

Lori Glenn

April 16, 2008 10:12 pm

— MOULTRIE — Rarely does the spotlight shine on an anesthesiologist, but Colquitt Regional Medical Center’s Dr. Charese Pelham and her support team deserve credit for saving a little girl’s life.
A 6-year-old girl came in to Colquitt Regional Medical Center Jan. 15 for a routine tonsillectomy. Anesthetist John Norman and a student anesthetist, Mandy Davidson, were in the operating room with her, and Pelham was elsewhere in the department keeping up through a handheld radio.
The case was ending. Everything up to that point was fine, she said, but the girl’s carbon dioxide output was going up. So Pelham had them push the bag breather faster, but the CO2 didn’t go down. Normal end-title CO2 levels are between 40 and 45, Pelham said. Norman radioed Pelham when the level was at 50. By the time she rushed down the hall, it had soared to 100.
Pelham quickly realized it was malignant hyperthermia (MH) crisis. MH, a rare genetic syndrome, hit national news at the end of March. It was the cause of the sudden death of a Florida teen cheerleader after she went in for a cosmetic procedure. MH can kill and can kill quickly if not stopped early. Temperatures can spike up to 112 degrees.
“It could cook your brain,” Pelham said.
Pelham set about trying to stave off temperature spikes by packing ice under the girl’s arms and groin area, and pushing iced saline and a muscle relaxer, dantrolene, intravenously.
To work an MH crisis takes between 15 and 20 people, Pelham said. She had at least 15 people working on the little girl, grabbing every available nurse and support personnel she could. They cranked the air conditioning to 62 degrees.
“This can shut your kidneys down, shut all your organs down and can kill you really quickly. Then the muscles start to contract and release huge amounts of potassium, which can stop the heart. You’ve got everybody working hard as they can,” she said. “We were freezing our butts off in there, but her temperature never got below 98.”
Malignant hyperthermia is an autosomal dominant genetic disease, meaning it is passed usually from generation to generation.
“Most of the time, you would never know you have it — ever,” she said.
It’s so rare — striking one out of every 15,000 to 20,000 people — most anesthesiologists go their entire careers and never see one, she said. And it’s indiscriminate.
“It doesn’t matter what surgery you’re in for,” she said.
MH can present within minutes of the trigger or a day later, she said. Certain triggers, such as some anesthesias, can set off MH. The most potent trigger is succinylcholine chloride or Anectine, which is used to induce muscle relaxation.
“It’s a very good drug. It’s a commonly used drug,” she said, adding advantages are quick onset and offset. “However, because of its potency as a possible MH trigger, we try to avoid using it on children if we can.”
Less of a trigger but a trigger nonetheless is anesthesia inhaled gases with the exception of nitrous oxide, commonly known as laughing gas.
Fortunately, Pelham has seen MH before. She was present during another case in Valdosta 10 years ago in an infant in for hernia surgery. An early indicator is an unexplained increased breath output of carbon dioxide and increased heart rate. A later sign is that body temperature will rise very quickly. The patient’s heart can go into ventricular defibrillation and cease blood flow. The key to saving this girl was the team’s quick reaction.
“Malignant hyperthermia can present as fairly mild, intermediate or severe. More often the presentation is severe, and you always have to treat it as it were severe. It can kill people. It has been known to kill people in as little as 15 minutes from the time it presented,” she said. “Most of the time if you jump right on it, you do have a little time but not a lot, and you really have to work it hard.”
Thorough preoperative exams are important, she said. Certain conditions, such as muscular dystrophy and strabismus (crossed eyes), are potential indicators, but this child had no indications whatsoever, Pelham said.
Other than a knowledge of family members having an anesthesia problem during surgery, there is no way to detect whether a patient going under anesthesia will have an MH crisis. A muscle biopsy can be done, but only a few centers in the U.S. test for MH. One is in Wake Forest, she said.
“If we know about it, no problem. There’s other things we can do,” she said.
Anesthesia has gotten so sophisticated through better monitoring tools, better drugs and training.
“It’s pretty rare to die from anesthesia,” she said.
The little girl eventually was transferred to Shands Hospital by helicopter. Pelham and her team worked on the girl for nearly six solid hours before the transfer, trying to keep her temperature down. The child remained in intensive care at Shands for a week, continuing to receive dantrolene.
Some time later, the mother of the child brought her by to see Pelham to thank her for saving her child.
“I hugged that kid. I thought I’d never let her go. It was great,” Pelham said. “... I’m a Christian. I strongly believe in God. God really blessed us.”
Pelham studied nursing at the Fletcher School of Nursing at Southern College before attending and graduating with honors from the University of Health Sciences at Antigua School of Medicine. Her anesthesiology residency was at Medical College of Georgia in Augusta, and she is board certified with the American Board of Anesthesiology, is a member of the Southern Medical Association, Georgia Society of Anesthesiologists and American Society of Regional Anesthesia and Pain Medicine. Pelham, as study coordinator at Aesthetic Surgery Center in Coral Gables, Fla., directed a team of researchers in conducting two long-term FDA approved studies regarding breast implants.
Pelham has volunteered in various capacities throughout her career to administer health care to underserved children. She is a native of Savannah, a member of Daughters of the American Revolution and is married to Dennis Farmer.