Anaesthesia anyone?

An animated Web video circulating among members of many anaesthesia departments depicts a fictional exchange between an orthopaedic surgeon and an anaesthetist. The surgeon wants to book the operating room for a case: "There is a fracture; I need to fix it" he intones.

The anaesthetist drills for more details about the case but the orthopaedic surgeon, like a broken record, merely repeats his need to "fix" the fracture. Boasting how there will doubtlessly be minimal blood loss in surgery, the orthopaedic obfuscates until finally revealing that the patient is actually dead and hence has no cardiac output that could possibly result in blood loss.

The exchange, exaggerated no doubt, illustrates the significant differences in the foci of two medical specialists when it comes to patient care. At least according to the anaesthetist.

So what exactly is anaesthesia?

It is that specialisation of medicine interested in the relief of pain and dedicated to caring for a patient from before the surgery, addressing anaesthetic related complications that may occur during the surgery as well as taking responsibility for pain relief in the early recovery period.

Prior to surgery, the anaesthetist monitors the patient's vital signs including blood pressure and heart rate before administering the anaesthetic, which may be general or regional. General anaesthesia makes a patient unconscious. Regional anaesthetic affects only a particular area, such as the leg or the arm. An intravenous line ("I.V.") to administer additional fluids such as special sugar and salt solutions may also be inserted. Various mechanical monitoring devices are also attached to the patient before surgery and these are relied upon also during surgery.

Canadian anaesthetist Paul Whang, 54, who practices at Humber River Regional Hospital just outside Toronto, Ontario has written a frank, surprising and at times funny account of his behind-the scenes recollections entitled Operating Room Confidential, in which he dispassionately observes the behaviour mainly of the patient but also of the surgeons and nurses.

According to Maclean's, Canada's only weekly national current affairs magazine, Whang was driven to write following a spate of surgical errors in Canadian hospitals. Surgical mistakes listed by Maclean's and not disputed by Whang include erroneous mastectomies and a surgeon cutting out a smoker's good lung, essentially killing the patient since he was left with the one, cancer-filled left lung.

Whang denies involvement in these cases but offers a statistic: "3.7 per cent of all hospital admissions [will involve] an error that results in some sort of disability or death or prolonging [a patient's] stay". And frankly admits that "errors are not singular instances but are products of a series of mistakes that accumulate over time".

Breaking the sequence of missteps that lead to a medical mistake is the path to minimising and hopefully, ridding the medical system of such errors. Whang explains that anaesthesia is one of the specialties that has looked into errors and become so much safer. "In the '70s the risk of an anaesthetic mistake causing death was about one in 10,000. Now it's 20 times safer". That change can be seen in his malpractice insurance premium. Malpractice rates in anaesthesia have been going down or have remained steady over the last five years in Canada. He adds: "Back then we considered this high rate and asked specialists from the aviation industry to look into it. Critical incident analysts found common reasons for the things that were happening. Anaesthetic machines weren't standardized…[and without knowing] …you [could] be doubling the anaesthetic vapours that you give somebody. So we standardized the machines".

Another innovation was the instigation of a protocol of "ticking the boxes" applies whenever somebody's having an operation. As a patient is wheeled into the O.R. a question is put to the room "Is this [say] Mr. Smith?" Everybody-anaesthetist, assistant, nurses, surgeon - has to reply "Yes." "Are we doing his right hand?" "Yes." "Are we doing minimal invasive surgery?" "Yes." And so on and so forth. Whang delights in confirming that such checklists have reduced O.R. errors by 30 per cent and mortality by 40 per cent, which he crows "is stunning".

Surgery is very much a team approach, he continues, but everyone still defers to the surgeon and indulges his quirk. Whang recalls that: "I know one guy who always wants [to listen to Toronto's 'classic rock' music station] Q107 [during surgery] and he won't start until it is [switched on]".

Every aspect of surgery is personalised by the surgeons. For example, closing wounds, Whang claims is prone to ritual: there's one surgeon who counts her sutures; if she ends on 13, she either takes one out or adds [another]".

Whang and his team chuckle like school kids when walking past the hospital cafeteria which sports multiple healthy eating posters with photos promoting the consumption of fresh fruit and vegetables cheek by jowl with slogans boasting the merits of nutrition, yet the same cafeteria is festooned with "stainless steel warmers holding sausages floating in pools of grease" and a deep fried assortments of other items.

Some fascinating topics are covered by Whang, in particular the occurrence of patients lying awake in surgery (up to 6 per thousand surgeries) In such cases, patients will feel something; be it the knife cutting through or similar. "I mean it's a horrible thing to imagine. Once you go to sleep [you remain continually anaesthetised]…but there are a number of factors that will increase the chance of being aware [of the surgical procedure]. One is genetics. Certain people have been shown to have a genetic predisposition to 'resist' the amnesic effect of anaesthetics".

Dr Whang enjoys sharing with his readers his insights into a host of medical specialists, including cardiologists; psychiatrists; neurologists; plastic surgeons; gastroenterologists and gynaecologists. But it's the orthopaedic surgeons who stand out given their strong personality traits. Whang recalls one who said "he didn't feel he'd done a good job unless [during a procedure] the blood splatters reached the ceiling".

And often slopping on to his notes and on to him.

This book is a light read prior to any hospitalisation. I closed the book with one overriding criticism and it's a big one: there is no comprehensive examination of the consequences of poorly applied anaesthesia or a patient's poor tolerance of the anaesthetic drugs, either of which can result in different levels of post operative cognitive impairment and possible catastrophic changes to a patient's quality of life.

Assuming the patient survives the surgery that is.