Anesthesia isn’t Easy-1

The Michael Jackson Edition

A doctor’s formative years are often telling.  If during the first year of medical school you fall in love with gross anatomy, you really have no choice but to pursue a career in surgery. After spending a year exploring the new and fascinating territory that is your personal cadaver, dissecting along tissue planes formed or nerves stretched as an embryo, some of us just can’t see putting it all aside.  Very soon, one realizes that the only physicians that need to know much about anatomy are surgeons and gynecologists.  Everyone else is pretty much practicing applied pharmacology.  Doesn’t matter where the iliopsoas muscle lives or if it’s your hypogastric plexus that’s pathetically paretic–write the script and see if the patient is better in a couple of weeks. If you love anatomy, if you pine for those early mornings smelling the formaldehyde perfume of your best dead friend, you’re going to be a surgeon.images

Similarly, anesthesiologists are practicing practical physiologists.  In the physiology lab, the subject (woof!) is attached to an array of monitors as the recently pubescent physician infuses various pharmacologic agents or inhaled mixtures of oxygen plus whatever.  Agent X goes in the vein, the heart rate goes up and the blood pressure goes down.  Reverse the effect with agent Y.  See what happens when you add a dash of inhaled agent Z.  At the end of the lab, give the happy subject a treat.  Seven years later, anesthesiologists are expertly doing the same thing to people.  Except for the treats.

During the formative years of every physician, but anesthesiologists in particular, one learns a great deal of respect for people physiology.  People are predictable, but not perfectly so.  We are men, or women, or children–not machines.  Herein lies the challenge.  Almost every time you give the patient your dependable drug, he responds as expected.  Almost every time.  It’s that “almost” that challenges every anesthesiologist.  The occasional patient that responds not quite as expected, a little too emphatically or a bit reluctantly.  Adjustments are titrated on the fly.  The rare, but really exciting, individual that displays a completely inappropriate response, such as anaphylaxis.  It is for this reason, this subtlety, that anesthesiologists are carefully trained, not born.  Like the practice of surgery, it is not a skill that can be mastered by reading the textbook, even if you’re really smart.  The really smart/experienced anesthesiologists know this especially well.  Then throw in the fact that the patient is having the trauma of surgery that the anesthesiologist must compensate for.  Some surgical procedures are more easily compensated for than others.  Some surgeons are more easily compensated for (see earlier blog post Never Say Oops in the OR“).

The practice of anesthesiology, however, suffers from one towering challenge above all; a challenge unique among all physicians.  Anesthesiologists must be perfect.  It’s a problem.  No other physician is held to such a high standard.  If you come to your surgeon with a tumor blocking your bowel, rest assured that he or she is going to do everything in his/her power to extirpate the neoplasm and restore your comfortable continuing existence.  But there will be pain.  And a scar or two.  Perhaps you’ll have some hiccup in your ability to digest really deep dish pizza from now on, but you’re happy to be alive.  Same with every other field of medicine–except anesthesia.  The practice of an anesthesiologist is to take a perfectly mentating person and put him into a profound coma.  But just for a while, then magically reverse that comatose state and restore the patient immediately to complete normalcy, preferably without any trace of the experience, not even nausea or a missing molar.  No fair if the patient is just about the same as before he had the life-saving procedure; say, he can remember almost everybody from his high school graduating class but has a slight problem coming up with the name of that girl he married.  Not good enough.  The patient must awaken happy, comfortable–normal.  Best case scenario, the patient emerges from anesthesia by completing the punch line to the joke he was reciting at the time of anesthetic induction three hours ago.  Extra points for an exceptionally satisfying dream during the procedure.  Nothing less than a perfect return to the pre-anesthetized state is acceptable.

As one can imagine, this can, at times, be a bit of a challenge.  Consider the inconvenient fact that nobody who’s normal lays down on an operating table.  Patients are sick, many very ill, some with years of undiagnosed/uncared-for illnesses now being subjected to the significant stress of an operation.  The most stressful thing this patient experienced in the previous ten years may have been lifting the television remote control.  Occasionally, the patient is horribly, critically ill.  Doesn’t matter–the anesthetic must be perfect, and certainly not the cause of even the sickest patient’s demise.  The surgery is allowed to kill him, but not the anesthetic.

So if you’ve ever had an operation, and you didn’t spend the entire time screaming, and you woke up pretty much thinking like your self thought before that whole operation thing: Thank your anesthesiologist.  Send him a card.  Or actually pay the bill.  Whatever.  Just don’t try it at home.