Taking the Mystery Out of Anesthesia
For many patients who are about to undergo surgery, something that frequently causes the most anxiety is the anesthesia that makes surgery possible. Fear of the unknown is very powerful, and anesthesia is very mysterious. Popular culture is full of portrayals of worst-case scenarios designed for thrills in medical dramas, but fears also stem from the fact that we don’t have a firm scientific understanding of what exactly consciousness is. This makes it hard to explain how consciousness can be suspended in a controlled way, which is part of what anesthesiologists do every day.
Anesthesiologists do a lot of reassuring and discussion about the safety of anesthesia with patients before a surgery. There are serious risks involved and it’s our job to keep people safe and comfortable. Our training as doctors includes a very deep understanding of the human body and the way drugs work. We are specialists, and although it may sound strange, we specialize in all patients. We must be familiar with every medical condition and every drug, since anyone may need surgery, whether or not they are healthy, having a heart attack, or are pregnant. We must be prepared to administer a safe anesthetic under any circumstances.
Scientifically speaking, there are five basic elements to the concept of anesthesia: the absence of awareness, the absence of memory formation, the absence of sensation, the absence of pain and the absence of movement. Each of these components can be selectively adjusted by the anesthesiologist when necessary, and there are different types of anesthesia that have different levels of each component. These types can be divided into three basic categories: sedation, general anesthesia and regional anesthesia. The type of anesthesia that is chosen for a particular surgery is carefully tailored to the individual needs of the patient and the type of procedure planned by the surgeon.
Sedation is a term which can refer to a wide range of states, from calmly awake all the way to unconsciousness. Many people often confuse sedation with general anesthesia, which is a state of unconsciousness so deep that patients require assistance with or even control over their breathing. Sedation is appropriate for minor procedures, and doctors may use drugs which are good at blocking memory formation but won’t necessarily make you fall asleep. An example of this would be using medication to relieve anxiety during a MRI scan or dental work. It is possible for a patient to be awake and aware during this type of procedure, but afterwards have no recollection of the event. To their mind, they may have a gap in their memory just as if they had been sleeping.
General anesthesia refers to the state which most people think of when imagining being “asleep” during surgery, but it is actually a very different state and much deeper than regular sleep. All five components of anesthesia are in effect under general anesthesia: there is an absence of awareness, memory, pain, sensation, and movement. “Waking up” while under general anesthesia is a very serious fear that many patients have, and it is made worse by misinformation from television and movies. Patients might even have heard a story from someone who had only very light sedation but expected to have no awareness. Although it is incredibly rare and unfortunate, it is possible that patients under general anesthesia can sometimes have some actual awareness. This typically occurs only in extreme situations in which it could be deadly to give the usual doses of anesthetic drugs, such as a severely bleeding accident victim.
Regional anesthesia refers to techniques that block sensation from a specific region of the body. This has no effect on consciousness by itself, so a patient will still be aware and be able to form memories unless we use additional drugs for sedation. Most patients prefer to be unaware during their surgery, but sometimes it is very important to be fully alert. For example, women having caesarean sections to give birth usually prefer to be wide awake to meet their babies, which is comfortably possible only with regional anesthesia.
While the anesthetic drugs we use are constantly evolving, some of the biggest advances in terms of patient safety have been made in monitoring the vital functions of the patient during surgery. Instruments have become more precise, easier to use and less invasive to the patient. While the surgeon is taking care of the patient’s surgical issue, the anesthesiologist is taking care of the patient, and we do that by measuring the functions of all the organs and adjusting their activities as needed to maintain life. Our responsibility is to operate and interpret these monitors before, during, and after the surgery. We do not leave the operating room while a patient is under our care.
Coordination with the surgeon and nurses is a continuous process. Our preoperative assessment team, led by Christine Gooley APRN-C, does a superb job getting patient information in advance. So we already know a lot about an individual patient when we meet her or him for the interview before any surgery to discuss the risks and benefits of the anesthesia plan. That’s the time for patients to ask questions about anything concerning their health and what’s going to happen to them under anesthesia. We also discuss any special aspects of the case with the surgeon in advance so we can agree on the plan.
That’s something I find tremendously valuable at a hospital the size of BMH. Because I see the same group of surgeons and nurses every day, we work very effectively as a team and can focus on the patient in a very caring way. At very large hospitals, it can be difficult to sort out what information needs to be communicated to whom, because the members of the team can be different from one day to the next. The familiarity we have here at BMH is a huge benefit that helps ensure a successful surgery and recovery for our patients.
Ithiel Fuller, MD, is one of the four physician anesthesiologists who practice at Brattleboro Memorial Hospital, and is a graduate of Marlboro College.