"Well, I'll have to page the surgical intern on call. Nothing is ordered because you have the epidural."

"Thank you," I called to the nurse as she left the room. The plain, institutional clock below the wall-mounted television read 8:00 p.m. My wife and I chatted idly while sitcoms played in the background. An hour passed. The pain grew worse. I pressed the nurse button on my hospital bed.

"Has the surgical intern ordered anything for pain?"

"Well, he checked the book and paged his senior resident. They said to give you this."

"What is it?"

"Famotidine." The nurse handed me a paper cup of water and the pill. Then she left again.

My wife and I laughed. "I guess you won't get heartburn," quipped my wife.

"I suppose they're giving me this because they gave me an injection of ketorolac yesterday. Oh, well." I took the famotidine.

Another hour passed, and the surgical intern wandered in. "How are you now?"

"The pain is worse than it was."

"My senior resident said that we should wait for a while." The surgical intern turned and walked out.

Great. He probably thinks that I'm seeking narcotic analgesics. I bet he's never had an incision from his xiphoid to his pubis. I guess I'll have to wait it out.

The plain clock stared at me. 10:30 p.m. The pain was worse. The nurse came to check my vital signs. "Your blood pressure is 98/50. Normal."

Normal, unless you consider my history of hypertension and my current pain. Mildly worrisome, actually.

"Excuse me," I interrupted. "Could you please tell me what my last hemoglobin level was?"

"It was 7.1 mg/dL this morning, I think. I told the surgical intern, but he said that the book says you don't need a transfusion."

The book? Oh, yes. I had seen a manual in the surgical intern's pocket when he did my preoperative history and physical. It contained algorithms and information on preoperative preparation and such.

"Thank you."

My preoperative hemoglobin level was 13.6 mg/dL. I had surgery yesterday, and by this morning the hemoglobin level had dropped to 7.1 mg/dL. I bet it's even lower than that now. It sure feels that way-I'm exhausted, even though I'm just lying in bed.

"Could you please page the anesthesia resident on the acute pain service? I'm really in a lot of discomfort. And I think that the surgical intern thinks I'm just seeking more painkillers."

"Sure." The nurse left. My wife looked concerned.

At about 10:45 p.m., the nurse returned. "The anesthesia resident is tied up right now with a pediatric patient. She'll be up here as soon as she can."

"Thank you."

Time passed. I looked at the clock when the pain had become unbearable. 11:30 p.m. The anesthesia resident hurried in, smiling. A new night shift nurse followed. The anesthesia resident quickly checked the pump that controlled the epidural anesthetic. "Oh, I see. Here's the problem. The line is kinked just inside the pump, but the sensor doesn't sense it. The readout indicates you're getting anesthetic when you're really not. So you've been without analgesia for hours. I'm sorry." I felt vindicated.

See, I told you so.

"I'll need to bolus your epidural catheter with more anesthetic," she continued. "It'll take a few minutes to get it ready. The medication will relieve your pain, but it may cause some hypotension." The surgical intern walked in.

"I think you should know that my hemoglobin level this morning was 7.1 mg/dL," I told the anesthesia resident. "I would bet that it's lower than that now."

"Why haven't they given you some blood?" asked the anesthesia resident as she prepared her syringes.

"Because the book says not to," the irate surgical intern chimed in defensively. "Not unless the hemoglobin level is less than 7.0 mg/dL."

"Please listen to me for a minute," I requested, looking at the surgical intern. "I don't want to tell you how to manage my care, but I'm a little concerned about how things are going right now."

The truth is that I'd like to avoid a catastrophe.

"My surgery ended late yesterday," I continued. "My hemoglobin level 18 hours ago-that is, 12 hours after the surgery-was 7.1 mg/dL. It was 13.6 mg/dL just before that. I'm sure it's even less now. It didn't have a chance to reequilibrate by the time of the last blood draw."

The surgical intern looked blank and unimpressed.

Come on. Listen.

"My Jackson-Pratt drain has also malfunctioned, so blood is leaking out around the drain. No one has measured the blood in the dressings, which the nurses have changed hourly since this morning. I've been taking corticosteroids for more than a year, and you've begun to cut back the stress doses of corticosteroids already. I have a history of hypertension, and my baseline blood pressure runs about 140/80. Now it's-"

The automatic blood pressure cuff promptly beeped and the display read-

"92/58," I added, "even though I'm in a lot of pain. If I were you," I said, watching the surgical intern closely, "I'd strongly consider giving a transfusion now."

Your book just doesn't take the whole clinical picture into account. I know you wouldn't be here if you didn't have some clinical judgment. Please, do what you think is right. Have confidence in yourself.

He paused and thought. "The book says your hemoglobin level has to be less than 7.0 mg/dL before we give you blood," he chanted. My heart sank. "But I'll ask my senior resident what he thinks."

"Thank you." As the surgical intern left, the anesthesia resident fiddled with the epidural pump. "I have to get to the intensive care unit for an emergency, so I'll do this now. I'm going to bolus your epidural."

A few minutes passed. The surgical intern returned. "My senior says the book says no transfusion."

"Would you please at least recheck my hemoglobin level?" I pleaded.

"Okay." He left.

"You should be feeling some relief of your pain now," the anesthesia resident said calmly.

"I am, but I feel a little lightheaded." I glanced at the automatic blood pressure monitor. It read 72/50. I closed my eyes and sank deep into the pillow. I could hear the nurse and the anesthesia resident scurrying about the room. My wife held my hand and squeezed.

Thank God they let her stay past visiting hours.

"Yeah. I definitely don't feel so well." I felt the head of the bed tilting downward. Everything looked dark and fuzzy. I felt so weak.

"Give him a 500-cc bolus of normal saline," the anesthesia resident called out.

"Hang in there, honey," my wife whispered into my right ear.

Then a male voice whispered into my left ear. It was the night nurse. "It's okay. I know how sick you are. I won't let them, the residents, well-you'll be okay."

Great, I can just see it now. The intensive care unit team gathered around my bed. Hypotension leading to acute tubular necrosis and renal failure requiring hemodialysis. Months in the hospital. Just great.

When I finally opened my eyes, the plain, institutional clock read 1:30 a.m.

"Your blood is here," announced the cheerful voice of the night nurse. He winked at me and carried in two units of packed red blood cells. The surgical intern appeared at the base of the bed. As the nurse connected the transfusion bags to my intravenous line, the surgical intern spoke.

"Your last hemoglobin level was down to 6.6 mg/dL. The book said to give you blood."

"Yeah, thanks," I replied weakly. The surgical intern silently hurried out.

I looked over at my wife. She looked exhausted but relieved. "Your blood pressure dropped to 46/20. But it's back up to 92/50 now. Get some rest." I slept.

In the morning, the attending surgeon stopped by, punctual and chipper as usual. "Looks like you got some blood last night."

Yeah. Just like the book said.