The introduction of anaesthesia in 1846 revolutionised surgery and pain management. The doctors you often see rushing to emergencies on television shows are likely anaesthetists. Yet, anaesthesiology is a poorly understood speciality, with many people believing that an anaesthetist simply leaves the operating theatre after administering anaesthesia. In reality, the anaesthetist is with the patient before, during and after surgery. And, contrary to cinematic depictions, one cannot sedate a person by placing a chloroform-soaked rag over her nose.
Dr Mamta Harjai, assistant professor in the department of anaesthesia at Ram Manohar Lohia Institute of Medical Sciences, Lucknow, completed her master’s at King George’s Medical University, Lucknow. When she is not in the operating theatre, she enjoys reading crime thrillers and practising yoga.
A customised expertise: Different patients require different types of anaesthesia, broadly categorised as general, local, regional and spinal. (Local anaesthesia impacts only a small part of the body, while regional anaesthesia covers a larger area, such as an arm. Spinal and epidural anaesthesia are types of regional anaesthesia.) There are further classifications, such as block anaesthesia, which numbs a block of nerves.
The choice of anaesthesia depends on the type of surgery, the body part involved and other factors critical in the success of surgery. Brain surgery, for instance, needs high-precision anaesthesia that numb only the operative area. When a patient is not under general anaesthesia, it is easier to identify complications, as the patient is breathing on her own and responsive to the anaesthetist’s queries. There are surgeries where a combination of anaesthesia types is used, with general anaesthesia typically reserved for longer surgeries or those anticipating significant blood loss. Anaesthesia generally kicks in within five to ten minutes, though epidural anaesthesia may take slightly longer.
A universal classification: We use the classification developed by the American Society of Anaesthesiologists to decide what kind of anaesthesia to administer. This has six categories. A patient without diabetes will fall in a category that is different from, say, a patient with controlled or uncontrolled diabetes. The existence of co-morbidities is the most important deciding factor.
Each patient is unique: That is why counselling is an integral part of an anaesthetist’s job. For instance, if a patient is terrified at the prospect of remaining conscious during surgery, even if it is a minor one, we counsel her on the benefits of regional anaesthesia, suggesting that she listen to her favourite music or talk to us during surgery. Counselling should always be positively framed―anaesthetists talk about the advantages of regional anaesthesia rather than the drawbacks of general anaesthesia.
Children are different: Anaesthetists do not think of children as mini-adults. They are a high-risk population, prone to more post-operative nausea and vomiting than adults.
Care and compassion: Dr Harjai administering anaesthesia to a patient | Pawan Kumar
Higher pain tolerance: Indians have a far higher pain threshold than patients in the west, where even inserting a needle requires patient consent. Often, in government hospitals, people from rural areas prioritise getting the surgery done over the pain involved in undergoing it.
Beyond the operating theatre: An anaesthetist’s role starts when the patient consults a surgeon. It is the anaesthetist who gives the final clearance for surgery. If a patient complains of dry cough, the anaesthetist checks whether she has bronchitis or asthma, conditions that need to be treated. In this way, anaesthetists become physicians as well. They are now referred to as “peri-operative physicians”, as they look at everything related to the operation. They try to identify pulmonary or cardiac complications in patients, to ensure that there are no risks involved and the patient can return to normal as soon as possible after the surgery. After the operation, it is the anaesthetist’s duty to manage pain. Since she manages the patient before, during and after the operation, she is best suited to understand the patient―which is why anaesthetists are put in charge of critical care units. Also, anaesthetists have a better overall view; she may be in neurosurgery one day, and orthopaedic surgery in the next.
Pain management: Sometimes, major surgeries require long incisions such as those reaching the epigastrium (the upper central region of the abdomen). Since its effect could hamper the patient’s ability to take proper rest, we do not take the patient off anaesthesia until the pain is manageable.
The master monitor: Once a patient has been put to sleep, the anaesthetist monitors every parameter such as pulse, blood pressure, respiration, temperature and urine output, even as the surgeons focus on surgery. Advanced monitoring systems have made this job much smoother. Anaesthetists now use fibre optics while giving nasal intubation (passing a tube through the nose to the windpipe). Earlier, we had to be guided by anatomical landmarks and the patient’s respiration.
Anaesthetists in critical care: Patients in critical care require the help of anaesthetists because they need to be hooked up to a mechanical ventilator. To do this, the doctor in charge needs to have expertise in airways, lungs and trachea. Anaesthetists (and doctors of respiratory medicine) are best equipped to manage this.
Not an unending sleep: Often, the biggest fear of those undergoing anaesthesia is that they would never wake up. But the risk of it happening is less than 1 per cent. Advanced techniques now help anaesthetists monitor the patient throughout the surgery.
Fear of waking up mid-surgery: Another concern is waking up during surgery because of anaesthesia failure. But in nearly all cases, anaesthetists maintain a pain-free, awareness-free state. They continually assess the depth of anaesthesia and adjust as needed.
Possible reactions: There is a very slim chance of complications, such as allergic reactions to anaesthesia drugs or airway issues, particularly in high-risk patients. But anaesthetists are trained to deal with such situations. In routine surgeries, the risk of complications is less than 1 per cent. Allergy to latex was once a concern, but the material is no longer used.
Epidural myths: A common misconception is that epidural anaesthesia (administered in the lower back) causes lifelong pain. Any pain from the procedure is caused by the thickness of the needle and should wear off with time. The myth probably arises from patients suffering from pre-existing back pain attributing it to the epidural. In fact, epidurals are highly effective for pain-free labour, though its effects can be delayed or slightly patchy.
The use of artificial intelligence: The first use of AI in anaesthesia was in the development of infusion pumps, which now enable us to administer drugs in precise doses. These pumps can also monitor anaesthesia depth and make adjustments as required. There are now AI algorithms that can analyse facial features to provide useful information such as the size of the mandible (lower jaw). AI-linked ventilators give us breath-by-breath analysis.
Questions to ask your anaesthetist: How many surgeries do you perform each month? How soon can I expect to be back on my feet? What type of anaesthesia do you specialise in?
Qualities of a good anaesthetist: An anaesthetist must have high empathy, as they need to understand the patient comprehensively. Attention to detail is essential, because if something goes wrong in the operating theatre, there may be just three or four minutes to react and save a patient. This calls for sharp reflexes, which is why anaesthetists are often compared to cheetahs. Anaesthetists must also have knowledge of procedures across specialities―for example, if a central venous catheter (a thin tube that delivers drugs to the heart) needs to be inserted, the anaesthetist must know all there is to know about the heart. They must be prepared to work long hours, moving between surgeries in different medical specialities.
Advancements in anaesthesia: Drugs that have faster onset time and very few side effects are a big advancement. Automated monitoring systems that are non-invasive and safer are now helping anaesthetists detect even the slightest change in a patient’s condition. Augmented reality is used in training, offering simulations to enhance learning.