October, 2007

ANESTHESIOLOGY: PUTTING SURGICAL APPREHENSIONS TO REST

The story of ether’s start in surgery is the stuff of soap operas. Dr. Crawford Williamson Long, MD of Jefferson, Georgia, was the first surgeon to use ether as a general anesthesia. He removed two tumors from the neck of James Venable in 1842 but failed to publish his findings until 1848. In the meantime, on October 16, 1846, William T.G. Morton—a dentist with no record of graduating from dental school—demonstrated the use of ether while surgeon Dr. John Collins Warren, MD busied himself with Gilbert Abbot’s vascular tumor. This historical and highly publicized event took place on the top floor of Massachusetts General’s Bulfinch Building, now known as the “Ether Dome.” There were others who claimed credit for ether’s first use in surgery, one who fell victim to chloroform addiction and was believed to have gone insane after suffering a stroke. Morton himself won the fame but not the desired patent, facing eventual bankruptcy.

I have had only one surgical experience to date. My husband snapped some shots during my C-section, so there is photographic evidence of all the instruments and colorful imagery involved, but I was happily anesthetized, chatting away about 10-mile races and real estate. While ether’s since been replaced with safer medications, I think I can speak for the general public in thanking Long, Morton, and the entire cast of characters for their troubles. Soon after Morton did his thing, the trend of using ether in surgery caught on. People’s Journal of London published an article claiming, “We have conquered pain.” Phew.

Anesthesia Today Anesthesiologists today spend their professional lives conquering pain, after attending four years of college, four years of medical school, four years of a residency training program, and a possible one-year fellowship in an anesthesiology subspecialty. The first sentence on the American Society of Anesthesiologists (ASA) website describes anesthesiology as the “practice of medicine dedicated to relief of pain and total care of the surgical patient before, during, and after surgery.” Dr. John Preston, MD of John Payne Associates directed me to this line when asked what he likes patients to know about his field. “It is the practice of medicine.”

The role of the anesthesiologist has expanded through the years. There was a time when it was this doctor’s sole responsibility to alleviate the pain of the patient during surgery. Today you will consult with your anesthesiologist or someone from a pre-operative clinic prior to surgery, and you will receive the doctor’s post-operative care before you are discharged. Your anesthesiologist is a peri-operative physician, and because of this vigilance the practice of anesthesiology is safer than it has ever been. “We know more how anesthesia affects the body,” says Preston. During the consultation, patients will reveal previous conditions, family history, current medications, and doctors will determine particular needs. Examples: If you have a heart issue, there may be a need for a stress test; if you have diabetes, the risk of post-operative infection increases. The pre-operative history and physical, coordinating all medical issues—“It all affects the surgical outcome.”

The anesthesiologist is not the only one with responsibilities. Preston strongly urges patients to gather information beforehand. “Patients spend more time doing research about what car to buy,” he says, and I do not doubt it. After my anesthesiologist explained the process to me, I nodded. And I certainly did not call him ahead of time—something else Preston encourages us to do if we have questions or concerns.

The Basics To save you some nickels on the call, however, I’ll lay out a few of the basics. To begin, there is analgesia and there is anesthesia. A drug given to relieve pain is an analgesic—it can be delivered through an IV, in a pill form, patch form, cream, or solution. A drug given to put you to sleep is an anesthetic. There are different types of anesthetics: inhalational (through a mask or tube), intravenous, local/regional, and analgesics given in large doses to maintain anesthesia during surgery.

There are three main categories of anesthesia: local, regional, and general. The first is a drug injected to numb a particular area in the body. The second is a drug injected near a nerve cluster, therefore numbing a larger region. As a result of the third, the patient is unconscious and will regain awareness in the recovery room after the process is reversed. Like any medical procedure, much depends on the patient’s desire, condition, age, past-experience, and on the doctor’s preferences and opinions. Preston gives the example of knee replacement surgery. A patient may choose a spinal with mild sedation, or a doctor can do the same procedure with the patient under general anesthesia. Preston’s caveat is age. If a patient is elderly, “I’d prefer to do a spinal because there’s less anesthesia and no breathing tube.” Even the surgeon’s opinion may differ from the anesthesiologist’s, but according to Preston, the surgeon defers 99% of the time. “Everybody wants a good outcome.”

Undergoing general anesthesia is daunting to some. My sister-in-law had an operation recently, woke with tears in her eyes and worried that she had said something embarrassing. A patient of Dr. Preston’s was furious with him post-op because he had apparently woken her mid-dream, as she was sitting down to a lavish dinner party! This unawareness can be disconcerting, but knowing some basics about general anesthesia may help ease your anxiety (perhaps not your embarrassment!). There are three stages to receiving anesthesia: induction, maintenance/monitoring, and emergence. With general, you are induced with either intravenous or inhalation anesthetics. Intravenous go directly into the bloodstream and will take about a minute to render you unconscious. Inhalation is used often with small children, and for this, a mask covers the mouth and nose. General anesthesia is maintained with inhalation or intravenous anesthetics, or a combination of the two. Often inhalation anesthetics are given through a tube or airway inserted after you are under. Emerging from general takes place with close monitoring—doctors make sure you are breathing on your own, that your vitals are normal, and that you have muscle control. Once they determine that all is well, doctors remove the tube/mask and sometimes give you reversal agents to counteract the effects of the anesthesia. You may not immediately recover from all of the effects of general anesthesia. For example, you may have numbness where you were anesthetized, or your reflexes and judgment may be a little off.

Technology plays a key role. Dr. Terry Walman, MD of Anne Arundel Medical Center explains that the pre-operative consultation may take place over the phone and the patient’s information keyed into the computer system, perhaps long before the day of surgery. Doctors can access the hospital records at any time and from any place—gone are the days of picking up lab slips by hand. There are high-tech monitors in the operating room so the anesthesiologist can keep a watchful eye on breathing, heart rate, blood pressure, etc. All of the vital information feeds into one display, and the anesthesiologist can add more to the modules, depending on the needs of the patient, so though there are standards, there is also variation. Medications may differ. For instance, of four anesthetic gases, individual doctors may prefer to use one over another. Doctors use varieties and combinations of agents depending on the patient. The monitor provides the anesthesiologist with the information, while the doctor synthesizes and responds accordingly.

Within anesthesiology, there is also a variety of specialties. There is pediatric, obstetrical, neurosurgical, critical care, cardiovascular, and ambulatory anesthesiology—to name a few. It depends on the practice model of a particular hospital whether doctors stick to their specialties. For example, if the volume of obstetric patients is high enough, the obstetrics anesthesiologist’s time is generally filled. However, says Preston, “A pediatric anethesiologist can do a gall bladder on an 80 year old.” Out of residency, anesthesiologists have been exposed to everything and can handle anything that comes along.

Who are all of these people? Once you are in the operating room, you may notice that the anesthesiologist is not necessarily going it alone. There may also be a few other folks in the room with you: an assistant, a perioperative nurse, a scrub tech, and possibly a resident. Surgery centers employ nurse anesthetists, who according to the American Association of Nurse Anesthetists (AANA) are “anesthesia professionals who safely administer approximately 27 million anesthetics to patients each year in the United States.”

You can sometimes choose your anesthesiologist. In obstetrics, there is not as much freedom, but for elective surgery, anesthesiology practices may receive requests. Your surgeon may be shy to recommend a particular anesthesiologist, but word of mouth may provide you with three or four names, and you can ask the surgeon with whom he/she has worked.

The Risks As with any discipline, there are risks; there is human error. But, the chance of anything going seriously wrong as a result of anesthesia is closing in on 1 in 500,000. There are checkpoints along the way. Equipment is consistently maintained and updated. All agents are safe and monitoring is much better than it was 20 years ago. That little clothes-pin thingee the doctor puts on your finger (pulsoximeter)—it measures the oxygen level and can save lives. Medications quickly metabolize and there is little residual effect. Doctors tell you not to eat 8 hours before surgery in order to avoid the risk of vomiting and that of aspiration, when the contents of the stomach end up in the lungs. Even if you are rushed into emergency surgery, there are things to be done to avoid aspiration. The two most common complications are chipped teeth and injury to the eye. Doctors use a metal instrument to help them see vocal cords and breathing tubes; sometimes bad teeth are dislodged or chipped. Once asleep, patients lose the protective reflexes of the eyelids, so there can be corneal abrasions, but doctors will tape eyelids to avoid this risk.

Rest Easy Though anesthesiologists may put you to sleep (I couldn’t resist!), they love their jobs because they enjoy the interactions they have with people—a not-so-subtle irony! Preston loves that with every patient comes a unique situation. And Walman: “It is not hard for me to justify how I spend my time.”

So when you are to have surgery, rest preoperative-easy the night before. If you happen to be heading in for a C-section, this might be the last good sleep you have for a long while.

Published October 2007 in What’s Up? Annapolis. Copyright 2007. Katie Regan Lenehan. All rights reserved. www.katiereganlenehan.com



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