Anesthesiologists are your heart, your lungs, your brain, your kidneys and liver and your consciousness… while the surgeon is operating
Some of our very senior citizens would surely have had the occasion to undergo some form of surgery 60 to 70 years ago. They may remember how, to render them unconscious, the medical staff would hold them down on the operation table while someone else would pour some pungent liquid (ether) over a mask placed on their face. Those were the days of ‘open method’. Most probably they would have had their tonsils removed by the ‘guillotine’ procedure.
Many archaic methods had been used for centuries to make patients unconscious before some invasive surgery was carried out. These included inflicting head blows, drinking a lot of alcoholic drinks, taking some homemade soporific concoctions. Otherwise, they would simply be pinned down on the operation table while fully conscious.
Nitrous oxide was first used as an anaesthetic gas in 1844 by Horace Wells, a dental surgeon to make a patient semi-somnolent and pain free; soon it was found not to be adequate. By 1846 ether was added as an adjunct, to be followed in 1847 by chloroform as an anaesthetic, introduced by the Scot JY Simpson. Subsequently as researchers, biochemists and physiologists put their heads together; better and safer gases and drugs were synthesized.
The aim of giving anaesthesia to patients is to tide them over that stressful period of their life while facilitating the work of the surgeon. Long ago the surgeon himself would be both the operator and the anesthesiologist, a practice which led to high morbidity, unfortunately. But as doctors became more versed in human physiology it was realized that giving anaesthesia to patients must be delegated to special medical staff, given that anaesthesia is full of risks; hence the setting up of a special department to be manned by anesthesiologists became mandatory.
In the 1950s and ’60s those anesthesiologists were diploma holders – the best at that time, but by the beginning of the 1970s degree holders in the speciality started to come back to Mauritius, and there was a gradual improvement in the administration of anaesthesia.
The main aim of anesthesia is to keep the patient pain-free and prevent him from moving while the surgeon operates. This could only be done by rendering him unconscious with anesthetics. Sometimes the patient receives only local anaesthesia – “cocaine” as is popularly known in Mauritius –, which is given by injection to the part of the body to be operated upon so as to numb it, and thus the patient does not feel pain. The same principle was extended to temporarily paralyze half of the body as in operations on the lower half of the body, or to provide relief to women in labour. In these cases the patient is fully awake.
The development of intravenous drugs (like barbiturates) or potent gases to knock out consciousness was itself a revolution; and potent painkillers of the family of morphine was a major step forward. Curare to paralyze the subject was the breakthrough. In South America the blackish extract from plants was used by Indians for hunting to paralyze their prey. This extract was investigated, and purer products were isolated to be used for operation.
These paralyzed patients needed to have their lungs ventilated by the anesthesiologists. Hence a whole gamut of instruments, tubes and machines had to be invented so as to maintain the oxygen and carbon dioxide level in the blood at optimum level.
That was the state affairs some decades back, when the triad of “unconsciousness – pain free — and paralysis” was well established.
Modern anaesthesia still relies on that principle, but the latest development has seen many technological innovations to put this concept on a more scientific basis. There are apparatuses to monitor the patient, to see to it that (1) he is really unconscious, one being the BIS index monitoring, which analyzes the brain waves on the EEG, to determine the level of consciousness.
Other apparatus can tell us (2) the degree of paralysis; no one wants the patient to move during delicate operations. And the patient has to be really (3) pain free – the anesthesiologist does not want to deal with someone who is experiencing pain and reacts adversely to it, and thus the use of very potent opiods. And as we are in the age of electronics and algorithms, the anaesthetized patient in very modern centres is monitored for bodily functions (sweating, rise of blood pressure, changing heart rates, twitching of muscles), and automatic, computerized adjustments are made to inject the required amount of drugs into the patient’s blood circulation. The modern anesthesiologist will soon find himself monitoring these monitors rather than observing his patient as he does nowadays. Yet these modern approaches will prove to be more accurate and more fail safe than older methods.
We in Mauritius are still far from these high tech concepts. But the job of the anesthesiologists still remains the continuous monitoring of the patients by the means available here.
Anesthesiologists are being more sympathetic to patients, who are stressed and anxious; drugs exist to reduce anxiety and are given before surgery; others are given to prevent nausea and vomiting (hence, the general advice that patients must always come fasting for a minimum of 6 hours before surgery). All is done to make the patient feel safe in the operation theatre. And many modern drugs exist to anaesthetize him safely; we anesthesiologists could use a combination of small doses of each – to produce extraordinary sedation and varying degree of unconsciousness — with due consideration to the age of the patient, to pre-existing other diseases (like diabetes or hypertension, renal dysfunction), to the degree of hydration, and to his mental state.
Of course, all of us are trained to visualize our responsibility as divided into three tiers: assessment and investigations before operation, intraoperative management during operation, and post operative follow-up. The ultimate aim is to see that the patient progresses through those three stages smoothly and with a minimum of discomfort and a maximum of safety.
Nowadays, the anesthesiologists are not confined to the operation theatre as before. Instead they are seen very often outside, specially in ICU where they are in charge of very sick patients with severe head injuries, other traumas and infections. In many places they are treating all sorts of acute or chronic pain in pain clinics; and they are called upon to provide pain relief through epidurals to women in labour, which requires a special set-up. In Mauritius this practice is more common in the private sector.
Some of you may wonder how general anesthetics work, that is how is consciousness knocked out. After 150 years of anaesthesia and innumerable theories no one knows for sure. For no one knows how and where in the brain consciousness is produced, if at all. The brain is silenced through a dampening of nerve signals inside it. Anaesthesia is like a sleep – but a controlled and a reversible one — where the anesthesiologist plays a very important role everyday of his professional life.
Anesthesiologists, who are celebrating the silver jubilee of the Association of Anesthesiologists of Mauritius during the coming weekend, are here to be vigilant for the patient. It is said that “anesthesiologists are your heart, your lungs, your brain, your kidneys and liver and your consciousness… while the surgeon is operating”…