How Anesthesiologists Save Lives
By WALTER S. ROSS
Summer
was always a fearful season in the days before polio vaccines. One of the worst
epidemics occurred in Copenhagen, Denmark, in 1952. Victims of paralysis began arriving at Beldam Hospital in
mid-July. Up to 50 new patients, mostly
children, poured in every day, as many as a dozen with clogged lungs and in
need of breathing assistance. There
weren’t enough iron lungs of cuirass (chest-size) respirators to go around and
even with the breathing machines, 80 percent of the breathing-paralysis
patients died.
The
frantic doctor in charge, H.A.C.Lassen, had an inspiration. He called in Dr. Bhorn Ibsen, a free-lance
anesthesiologist working at another hospital.
Lassen knew that anesthesiologists had had to become experts I keeping
patients breathing during surgery, but nobody had ever thought of applying
their expertise outside the operating room.
Dr.
Isben’s first patient was a 12-year-old girl, paralyzed and gasping for breath,
literally drowning in her own secretions.
He asked a surgeon to do a tracheonomy—that is, to make a hole directly
into her windpipe. Isben inserted a
plastic tube and pumped her lungs clear of fluid, then attached a simple
anesthesia apparatus to her neck—a Y-shaped tube, canister of oxygen and a
breathing bag. But he used the
breathing bag to squeeze a mixture of air and oxygen into he lungs, instead of
an anesthetic. Soon the child’s body
relaxed. Her skin became pink. She was kept on the breathing device until
she could breathe for herself.
From
them on, all new patients with breathing paralysis—total of 318—were given a
tracheotomy and the same kind of breathing apparatus. Every medical student in Copenhagen volunteered to squeeze the
breathing bags by hand, in eight-hour shifts.
Whereas 26 of 30 patients had died on the old respirators, 200 of the
318 lived—and 175 recovered enough breathing capacity to leave the hospital.
This
dramatic death-to-life reversal made medical history. Doctors all over the world realized that they had a new
life-saving resource in the mastery of artificial ventilation by
anesthesiologists.
Today
the anesthesiologist is being called in every breathing emergency, from birth
to attempted suicide. For example, if a
mild anesthetic commonly given to mothers during childbirth anesthetizes the
baby so that he cannot begin to breathe, an anesthesiologist may put a plastic
tube into his windpipe and give him lifesaving oxygen. Should a emphysema victim be struck with
bronchitis or pneumonia—and be dying from exhaustion in his efforts to get
oxygen—and anesthesiologist will breathe him by machine for a few hours, of
even days, giving his body vital rest.
The anestheologist also gives artificial ventilation to heart-attack
victims with total cardiac arrest; to tetanus patients whose breathing is
strangled by a muscular spasms; to people who have taken overdoses of
barbiturates, which temporarily paralyze the nerves controlling breathing.
Ventilation
is just one of the lifesaving skills mastered by anesthesiologists since
surgical anesthesia was first demonstrated, practically, with either by dentist
William Morton in 1846—an event since equated with such medical milestones as
the discovery of vaccination by Edward Jenner and the introduction of antiseptics
by Joseph Lister. Over the years,
specialists in anesthesia have come a long way from the guesswork application
of either and nitrous oxide to the precise control of dozens of powerful drugs
that may be inhaled, injected, given orally or rectally.
Anesthesiology
is now one of medicine’s most versatile specialties. The anesthesiologist can take away consciousness of obliterate
feeling locally, paralyze the body and relax the muscles, control the blood
flow and reduce blood pressure to prevent bleeding, even largely suspend the
body’s needs for oxygen by cooling.
Most
patients never see the facemask through which the inhalants are breathed. Asleep by the time they reach the operating
anteroom, they remember only the premeditations—the tranquilizer or barbiturate
and morpheme injection administered an b\hour before the operation, plus a
belladonna-like drug which stops tissue from secreting fluid, giving the
surgeon a dry “field” to work in.
Although
the anesthesiologist’s surgical patients are unconscious most of the time he is
with them and have little notice of his role, most leading surgeons recognize
that anesthesiology has extended their skills into fields that would have been
inconceivable a few years ago. Dr.
Roald Grant, surgical consultant to the First marine Division in the Koerean
war, said, “Our front-line hospitals were as effective as their
anesthesia. When they had an
anesthesiologist to keep the severely wounded alive, the surgeons could make
their repairs. Without the anesthesiologist,
many of the wounded would have died.
The same thing was true in Vietnam.”
Surgeons
often ask anestheologist whether a patient can stand anesthesia and a long
operation. And it’s not uncommon during
surgery for the anesthesiologist to warn that a patient is weakening and that
the operation should be stopped.
Several years ago, a surgeon was operating on a cancerous intestine in
Columbia-Presbyterian Medical Center in New York City. His plan was to remove part of the colon and
much surrounding tissue. The patient’s
blood pressure sank to 70/50 during the surgery—too low—and, on the
anesthesiologist’s advice, the surgeon closed the abdomen without completing
his planned procedure.
“The
patient’s electrocardiogram didn’t look right,” Dr. Emmanuel M Papper, then
head of the anesthesiology at the center, told me. “We couldn’t be sure, because we couldn’t put electrodes on his
chest—they would have interfered with surgery.
But when we could do a full EKG, we found he’d had a heart attack on the
table. Interposing surgery gave him a
chance to recover.” The surgeons
finished the operation later.
Such
teamwork, supported by a wide range of new anesthetic drugs and electronic
controls, has made formerly impossible surgery commonplace. I once saw a surgery-anesthesiology team do
two open-heart operations the same date at Columbia-Presbyterian. The first patient was a 70-year-old man with
a leaky heart valve. He went to sleep
quickly with little premeditation, and was kept asleep on a very low dose of halothane
(a modern inhalant that has largely replaced ether—it is non-explosive, and
doesn’t leave patients nauseated) and nitrous oxide. Catheters were inserted into a vein and an artery in his groin to
measure blood pressure, and a tube was slipped into his windpipe for later
ventilation.
A
special stethoscope was put into his esophagus less than a half-inch form his
heart. This was connected to an
earpiece worn by the anesthesiologist molded to his ear so that he can wear it
without discomfort for hours, leaving the other ear open to hear the nurses and
surgeons). Through this, the
anesthesiologist can listen to both the heart and the lungs (like a drumbeat
with an organ background) and detect the first signs of emergency.
During
the ensuing four-hour operation, surgeons inserted tubes into an artery and a
vein connected to the blood –oxy-generating machine—the “heart-lung”
machine—that would cleanse and oxygenate the patient’s blood. Then they cut into the heart, removed the
bad valve and successfully replaced it with a man-made one.
The
second patient was a 14-month-old infant with a hole in the wall inside his
heart. He was overactive and fearful,
so the anesthesiologist, Dr. Richard Patterson, decided not to show him the
face mask. Instead, he called for an
odorless, but explosive, gas—cyclopropane [often used because children can’t
smell it, and so don’t panic]. Everyone
in the room was grounded; all electrical equipment was turned off. As De. Patterson moved the open end of the
gas tube near the baby, the child began to breath the gas, his movements slowed
and he fell asleep. Now a mask was
slipped over the tiny face, and a mixture of halothane and air replaced the
dangerous gas. The hole was quickly
repaired.
In the
both cases, the anesthesiologist was in charge of the patient’s blood
volume. He had a panic-type thermal bag
with chilled pints of the proper type of blood. Some of this was used to prime the oxygenating machine. His assistants weighed blood-soaked sponges
during the operations, and he would ask the surgeon how much blood was leaking
inside the incision so that blood replacement could be estimated exactly.
In the
case of an infant, the thimbleful of lost blood is the equivalent of a
hemorrhage in an adult [a baby has less than a pint of blood in his body; and
adult has a six quarts], and, in replacing blood, too much is as dangerous as
too little. Excess can overload the
heart. After each operation Dr.
Patterson and the surgeons went along as the patient was wheeled into an intensive-care
room. In many hospitals, this room is
now under the supervision of an anesthesiologist.
Such
close control of patients before, during and after surgery has saved countless
lives, and has, infect, made death from surgery of anesthesia a rarity. Of some 20 million surgical operations done
under anesthesia last year in the United States, it is estimated that one
patient in each 4500 operations died of surgical caused, and one in 10,000 of
anesthesia.
Anesthesia’s
first and basic role—the suppression of pain—has led to new knowledge of pain;
where it originated, how it travels, and how to block it locally.
The
anesthesiologist now treats patients outside the operating room who suffer
amputation stump pain or the chronic pain resulting from such diseases as
angina pectoris, advanced cancer, Parkinson’s disease. “Chronic pain is a disease,” said Dr
Papper. “If the pain can be relieved
without damaging the patient, he’s considerably improved, even if not cured of
the basic illness.”
One
morning at an outpatient clinic in Liverpool, England, I watched an
anesthesiologist treat several patients.
One was a woman suffering the agony of advanced cancer. The doctor felt for the source of the pain
in her back, pressing with his fingers until the patient said, “there.” He plunged a long hypodermic needle into the
spot for a trial injection. For an
instant she stiffened; then, after a few minutes, she smiled. “Feels better already,” she said.
“We use
lignocaine, a form of Novocain,” the doctor told me. “When the dentist gives it to you, you feel local number ness for
an hour. But if we can put it directly
into a nerve that transmits pain—which may be quiet far from where the pain is
perceived—it may work for months. We
don’t know why.”
One of
the doctor’s patients comes in about once every two years with back pain. He hobbles in bent over, barely able to
move. A half—hour later, he strides
out, erect and smiling—and doesn’t come back for another two years.
“Our
results aren’t often so dramatic,” the anesthesiologist said to me. “We don’t have a one-shot cure. If the injection doesn’t work, we may try
killing some nerves with alcohol of phenol.”
With all
that anestheologist can do to save lives and relieve pain, you’d stink the
specialty would be booming. It hasn’t
boomed in the United States. One reason
is lack of research money. Few
outstanding leaders—the men who inspire students to enter the specialty—have
thus been attracted to anesthesiology.
And only a handful of medical centers offer enough exposure to
anesthesiology research and training, of give anestheologist full recognition
for the entire can do—or the authority to do it. In these places, spirit is high.
But, generally, anestheologist has image trouble, woven among
doctors—many of who still tend to regard them as technicians, subordinate to
surgeons.
In Great
Britain, anestheology is a leading medical specialty, attracting nearly 10 per
cent of all doctors—as against only 3 percent in the United States. We have about 12,000 doctors trained in
anesthesiology; we need thousands more.
To bridge this gap, in some hospitals general practitioners may give
anesthesia; other hospitals use specially trained nurses.
There
are programs, some government-financed, to make up our deficit in anesthesiologists. But closing the gap will take years. Meanwhile, more knowledge of the work that
anesthesiologists do in and out of operating rooms will help build the morale
and numbers of these overlooked specialists who save so many lives.
