The
Doctor Behind the Mask
Most people think of their anesthesiologist only as the "doctor
behind the mask" who helps them sleep through surgery
without pain and who wakes them up when surgery is over. Let's
lift the doctor's mask and take a look at the responsibilities
and education of the anesthesiologist.
Role in Modern Medicine
Most people believe that anesthesiologists are the doctors
who administer medications which keep them from feeling
pain and sensations. However, few people realize that beyond
ensuring the patient's comfort, today's anesthesiologists'
primary role in the operating room is to make informed medical
judgments to protect and regulate the patient's critical
life functions that are affected by the surgery being performed.
Also, these medical specialists are the doctors who will
immediately diagnose and treat any medical problems that
might arise during surgery or the recovery period.
Anesthesiologists need a wide range of knowledge about
medications, internal medicine, how the human body works,
and its responses to the stress of surgery. As physicians,
anesthesiologists are responsible for administering anesthesia
to relieve pain and for managing vital life functions, including
breathing, heart rhythm, blood pressure, and brain and kidney
functions during surgery.
As doctors, they manage, and treat any medical problems
which may be present before surgery or that may develop
during or immediately after surgery. Those patients who
have received medical evaluations or treatment from their
physicians before surgery must have that same medical care
continued during surgery by their anesthesiologist.
Prior to surgery, anesthesiologists evaluate the patient's
medical condition and formulate an anesthetic plan for each
individual patient taking into consideration that patient's
physical status. During surgery, advanced technology is
used to monitor the body's functions. Anesthesiologists
must interpret these sophisticated monitors in order to
appropriately diagnose, regulate and treat the body's organ
systems while a personalized, very delicate balance of anesthetic
medications is administered. In some hospitals, nurse anesthetists
may assist the anesthesiologists with the monitoring responsibilities.
However, it is the anesthesiologists who are responsible
for the interpretation of that monitoring and who make educated
medical judgments concerning the patient's responses, and
when it is and when it is not appropriate to treat the patient.
At the conclusion of surgery, anesthesiologists reverse
the effects of the anesthetic medications, and return the
patient to consciousness once again.
They maintain the patient in a comfortable state during
recovery, and are involved in the provision of critical
care medicine in the intensive care unit. Anesthesiologists
also are involved in the practice of chronic pain management.
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Medical Training
Anesthesiologists are doctors of medicine who, after graduating
from college with a strong background in physics, chemistry,
biology and mathematics obtain a medical doctorate degree
after completing four years of medical school.
After medical school, today's anesthesiologists learn the
medical specialty of anesthesiology during an additional
four years of postmedical school training (one year of internship
and three years in an anesthesiology residency program).
During the first year, anesthesiologists must complete
training in diagnosis and treatment in other areas of medicine-such
as internal medicine, neurology, obstetrics, pediatrics
or surgery-or complete a rotating internship where they
spend an equal amount of time training in each of the other
areas of medicine. Today's anesthesiologists then spend
three intensive years of training in anesthesiology learning
the medical and technical aspects of the specialty. In addition,
they may further specialize in a subspecialty, such as neurosurgical
anesthesiology, by completing one to two more years in a
subspecialty training program.
But, even when residency training is completed, anesthesiologists
continue to spend a great deal of time in special courses
and seminars studying new medical advances and anesthetic
techniques throughout their careers. Today's anesthesiologists
are educated in cardiology, critical care medicine, internal
medicine, pharmacology and surgery to be able to fulfill
their role in modern medicine.
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TO OUR PATIENTS
This newsletter has been prepared to help you and your family
better understand what modern anesthesia is, so that you
may help make well-informed decisions about your care. As
physician specialists, our main goal is to provide you with
the best medical care possible during your surgery as well
as safe relief from pain.
We hope you will read this newsletter so that you can work
with your anesthesiologist to make the most appropriate
decisions about your anesthesia. We anticipate that this
newsletter will answer many of your questions, but it cannot
answer them all. When you talk with your anesthesiologist,
please ask about any questions or concerns you have.
We believe that the best anesthesia care for you will result
from you being a cooperative, confident and well-informed
patient, while we, as physicians, are likewise well-informed
in addition to being vigilant and caring.
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The Nervous System - Your Body's
Communication System
Your body has an amazing communication system composed of
a network of billions of nerve cells which interconnect
with your brain and spinal cord. This network is called
the nervous system and spreads messages throughout your
body including your internal organs and skin's surface.
Through this network, constantly changing electrochemical
signals transmit information from the outside world to your
brain, including messages of injury that translate to your
brain as pain sensations. These signals travel incredibly
fast from the tip of your nerve endings to your spinal cord,
and on to various areas in your brain where they're processed
into emotions, sensations, thoughts and actions.
The three different types of anesthesia-local, regional
and general-interrupt these pain signals at specific points.
Think of your nervous system as a telephone system in an
office; your brain is the switchboard your nerves are the
telephone cables and the parts of your body that are experiencing
pain are the telephones.
For example, your foot may need minor surgery and your
doctor has decided that local anesthesia will be sufficient.
Local anesthesia only will numb a small area, such as part
of your foot. The numbed nerves do not allow the 'pain signal'
from your foot to be sent through the nervous system. It
is as if the phone is 'off the hook' and the phone message
cannot be sent.
Perhaps you need surgery to repair a hernia and regional
anesthesia is chosen. Regional anesthesia is used to eliminate
pain in a larger part of the body by temporarily blocking
large groups of nerves or the spinal cord so that the pain
signal cannot reach the brain. If a telephone cable broke,
all the phones in one area of the office would temporarily
stop operating and no messages from that entire area could
be sent to the switchboard.
Finally, you may need a major operation, such as heart
surgery, and your anesthesiologist decides that general
anesthesia is best. General anesthesia temporarily makes
you unconscious so that your brain does not perceive any
pain signals from the nervous system. During that time,
no messages are processed, and you cannot experience pain
or other conscious sensations. It is as if the switchboard
operator is on a coffee break and is not there to connect
the phone calls.
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The Conquest of Pain
Try to imagine today's health care without surgery. It's
almost impossible. Now try to imagine surgery without anesthesia.
Equally impossible. Without anesthesia, many of modern medicine's
greatest benefits simply would not exist.
More than 25 million surgical procedures are performed
each year in the United States alone. Clearly, the health
and well being of almost everyone you know has been touched
by the science of anesthesiology.
These and many other surgical procedures now considered
routine are carried out in hospitals and outpatient settings
by the thousands every day. You usually take them for granted-and
you should; current safety figures are impressive. So much
so, you may lose sight of how long a way physicians have
come in only the last 100 years, and even in the last five
years when more lengthy and complex operations than ever
before have been made possible by recent advances in anesthesiology.
Today's anesthesiologists now practice one of the most
complex disciplines of medical specialization. These doctors
command a vast amount of medical knowledge about the human
body, about drugs and how they act upon the body, and about
the sophisticated technology used to track every major organ
system during surgery and to administer drugs in a variety
of ways.
During a major operation, anesthesiologists choose from
a variety of drugs to fulfill many different functions such
as stopping pain, making the patient unconscious, and relaxing
the body's muscles. To do this, they may administer inhalational
anesthetic agents, sedatives, muscle relaxants and many
other drugs that act to help maintain normal body functions.
The anesthesiologist must skillfully orchestrate all of
these drugs in accordance with the individual medical and
surgical needs of each patient.
At the same time, anesthesiologists have improved techniques
for turning off a patient's response to pain in specific
regions of the body; this means that patients may remain
conscious and recover more quickly after certain surgical
procedures.
Only 40 years ago, administering ether through a mask and
monitoring the patient with a simple stethoscope was considered
to be the state of the art. Today, ether is not used for
anesthesia and very sophisticated monitors are standard
procedure. Currently, drugs designed molecule by molecule
on computer screens for more effective applications within
the human brain are in use in today's operating rooms. Dramatic
advances in technology continue to create monitoring devices
with even more subtle and accurate measuring capabilities.
National and international anesthesiology conferences are
regularly convened to transmit the explosion of research,
new information and new applications for patient care.
The future of medicine-surgery in particular-will continue
to benefit from new advances in anesthesiology. All of this
progress will allow anesthesiologists to better perform
their most crucial and basic task: safely caring for the
health, comfort and quality of life of all their patients.
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Anesthesia for Same Day Surgery
Today's new safe, short acting anesthetic medications and
sophisticated monitoring devices enable anesthesiologists
to provide their patients with the most up-to-date and best
medical care possible on a daily basis. As a result, an
increasing number of surgical procedures are performed safely
on an outpatient basis. This means that patients may come
to the hospital, have surgery and go home, all on the same
day. If you are a same day surgical patient, you now may
safely undergo one of many, elective surgical procedures
without staying overnight in the hospital away from your
family and familiar surroundings. You may continue your
recuperation the same day in the comfort of your own home
and often avoid costs which insurance might not cover.
Same day surgery usually is elective and can range in duration
from a few minutes to a few hours. It is frequently performed
in the ambulatory surgical center. The anesthetic techniques
that are used today enable you to continue your recovery
safely at home. These techniques may be applied to all forms
of anesthesia including: local anesthesia with intravenous
sedation, regional nerve blocks, and general anesthesia
where you are unconscious during surgery.
After surgery, you will be taken to the Post Anesthesia
Care Unit (PACU), commonly called the recovery room, and
closely watched for any immediate postoperative problems.
When you meet the discharge criteria which have been determined
specifically for you-based on your personal medical condition,
the type of surgery and the criteria of the ambulatory surgical
center-you will be released to go home with a reliable friend
or family member. It is extremely important that you arrange
for a responsible adult to take you home from the ambulatory
surgical center because your coordination and various reflexes
may be impaired for at least 24 hours making normal activities,
such as driving, difficult.
If you are having same day surgery, the goals of your anesthesiologist
are: to provide you with the best medical care possible,
to deliver safe and satisfactory pain relief during your
surgery, and to return you to an alert, awake and comfortable
state of health so that you may be discharged within a few
hours. To achieve this, your anesthesiologist takes into
consideration your current and past medical condition, as
well as the type, location and estimated length of the surgical
procedure.
In order to achieve a clear understanding of your needs,
information regarding your medical condition will be obtained
by your anesthesiologist either on the day of surgery, the
day preceding surgery, or a few days before surgery during
your preoperative visit. Frequently at such preoperative
visits, blood and laboratory tests, or other preliminary
examinations, such as ECG or x-rays will be completed.
This prior evaluation gives you the opportunity to discuss
your medical history, various anesthetic options and their
risks, and pertinent questions of concern with the anesthesiologist.
It also gives you the chance to learn about the many safety
precautions that your anesthesiologist will provide during
your surgery.
You should bring a list of all medications that you take
on a regular basis or have taken recently with you to the
preoperative visit. It is best to include the dose information
from the medication label on your list. The dose is commonly
shown in milligrams (mg). For example, "100 mg"
stands for 100 milligrams. Providing your anesthesiologist
with your detailed medical history and drug list is very
important. This information, combined with the laboratory
data from your tests, is the basis upon which many anesthetic
decisions are made.
For most procedures you will be told to fast the night
before your operation. It is very important that you do
not eat or drink anything during that time unless otherwise
instructed by your anesthesiologist. (See the question,
"Why are patients not allowed to eat or drink anything
before surgery?" for more information about fasting.)
If after your surgery you do not feel well or experience
pain, tell the nurses or anesthesiologist in the Post Anesthesia
Care Unit so they can determine how best to help you. You
shouldn't be reluctant to tell them how you feel or ask
any questions you may have. You will not be released to
go home until you have recovered sufficiently from the anesthesia.
Occasionally, some patients need additional care or experience
difficulties following surgery and may need to be observed
or treated in the hospital over night until they are well
enough to go home.
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Good Questions
May I choose my anesthesiologist?
This question is a very common one as today more and more
patients search for medical specialists. Many people find
their doctors through recommendations from other doctors
or through family and friends and the same situation exists
when choosing your anesthesiologist. You do have a choice
as to who your anesthesiologist will be. However, you must
make that choice known in advance so that arrangements may
be made to honor your request. In most situations where
no request exists, the surgeon who has scheduled the operation
will arrange the services of an anesthesiologist with whom
he or she is familiar. However, if for any reason you are
not comfortable with the recommended anesthesiologist, you
may request a different anesthesiologist.
Are there different kinds of anesthesia?
There are three main categories of anesthesia: general,
regional and local. Each has many forms and uses.
In general anesthesia, you are unconscious and have no
awareness or other sensations. There are a number of general
anesthetic drugs. Some are gases or vapors inhaled through
a breathing mask or tube and others are medications introduced
through a vein. During anesthesia, you are carefully monitored,
controlled and treated by your anesthesiologist, who uses
sophisticated equipment to track all your major bodily functions.
A breathing tube may be inserted through your mouth and
frequently into the windpipe to maintain proper breathing
during this period. The length and level of anesthesia is
calculated and constantly adjusted with great precision.
At the conclusion of surgery, your anesthesiologist will
reverse the process and you will regain awareness in the
recovery room.
In regional anesthesia, your anesthesiologist makes an
injection near a cluster of nerves to numb the area of your
body that requires surgery. You may remain awake, or you
may be given a sedative. You do not see or feel the actual
surgery take place. There are several kinds of regional
anesthesia. Two of the most frequently used are spinal anesthesia
and epidural anesthesia, which are produced by injections
made with great exactness in the appropriate areas of the
back. They are frequently preferred for childbirth and prostate
surgery.
In local anesthesia, the anesthetic drug is usually injected
into the tissue to numb just the specific location of your
body requiring minor surgery, for example, on the hand or
foot.
May I request what type of anesthesia I will receive?
Yes, in certain situations. Some operations can be performed
using different anesthetic procedures. Your anesthesiologist,
after reviewing your individual situation, will discuss
any available options with you. If there is more than one
type of anesthetic procedure available, your preference
should be discussed with your anesthesiologist in order
for the most appropriate anesthetic plan to be made.
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What happens after I lose consciousness during general
anesthesia?
Beginning Phase A great deal besides surgery takes place
between the beginning of your anesthesia and your return
to consciousness in the Post Anesthesia Care Unit. Your
anesthesia probably will be started with an "induction
agent"; a common one with which you may be familiar
is sodium thiopental (Pentothal®). You may have heard
that this induction agent is used as a "truth serum";
that is a myth. The real truth is that thiopental is used
basically during the first step (induction) of your anesthesia
when you "drift off to sleep" and lasts only a
few minutes.
In order to keep you anesthetized, your anesthesiologist
administers and regulates additional and more potent medications
that are necessary to maintain your anesthesia for the rest
of the procedure. Some of these medications are injected
into your veins and others, such as nitrous oxide, are inhaled
through your lungs because they are gases. Inhaled gases
are administered to patients who receive general anesthesia
with "oxygen" being the most important gas. These
gases are administered either through a mask or a special
breathing tube which is inserted into your windpipe (trachea)
depending upon your surgical procedure and physical condition.
Middle Phase Exactly which medications will be administered
to you during anesthesia will be determined by your physical
responses and how they will be affected by the type of surgery
you are having and by your medical status. Therefore, your
anesthesiologist will carefully tailor your anesthetic just
for you. Some of these medications will be the actual anesthetic
agents that help you to remain unconsciousness and experience
no sensations, while others are administered to regulate
your vital functions such as heart rate and rhythm, blood
pressure, breathing, and brain and kidney functions.
Your anesthesiologist constantly is monitoring, evaluating
and regulating your critical body processes because they
can change significantly during the operation due to the
stress and reflexes from surgery itself, the effects of
the anesthetic medications and your medical condition. For
example, in most operations specialized equipment is used
to actually control the patient's every breath. (This is
because certain medications temporarily decrease breathing
capability, which is further reduced by necessary muscle
relaxants.)
Your anesthesiologist also is responsible for and will
treat any medical problem which you may develop during surgery
such as a blood pressure problem. However, your anesthesiologist
wants to help prevent any medical problems by using and
interpreting today's sophisticated monitoring equipment
and knowing when and how to treat your body's responses
to surgery.
Recovery Phase When surgery is completed, the recovery
phase is carefully timed and controlled. Anesthetic agents
are discontinued and new medications may be given to reverse
the effects of those administered previously. Body temperature,
breathing, blood pressure, and other functions begin to
normalize. Before your total recovery, you may receive some
medications to decrease postoperative discomfort. All of
this is calculated precisely under the supervision of your
anesthesiologist to permit you to return to consciousness
in the recovery room unaware of what has occurred during
the operation.
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Why are so many questions asked about my past and present
medical conditions?
Because anesthesia and surgery affect your entire system
it is important for your anesthesiologist to know as much
about you as possible.
You already realize that your anesthesiologist is responsible
for your anesthesia to make you comfortable, but in addition,
he or she is also responsible for your medical care during
the entire course of surgery. Therefore, it is important
to know exactly what medical problems you have and any medications
you have been taking recently since they may affect your
response to the anesthesia. You also should inform your
anesthesiologist about your allergies, any hard drug or
alcohol usage, and past anesthetic experiences.
Your anesthesiologist must be very familiar with your medical
condition so that the best anesthetic and medical care may
be provided throughout your operation. This important knowledge
will allow your anesthesiologist, as a doctor, to continue
your current medical management into surgery which will
help prevent complications, and expedite diagnosis and treatment
of any medical problems should they occur. Your continued
medical management during surgery is necessary to help facilitate
your speedy recovery.
Why talk about drinking and smoking?
Cigarettes and alcohol affect your body just as strongly
and sometimes more than any of the medically prescribed
drugs you may be taking. Because of their various effects
on your lungs, heart, liver and blood, to name a few, cigarette
or alcohol consumption can change the way an anesthetic
drug will work during surgery, so it is crucial to let your
anesthesiologist know about your consumption of these substances.
This is also true, especially true, for so-called "street
drugs"-marijuana, cocaine, amphetamines and the rest.
People are sometimes reluctant to discuss these things,
but it is worth remembering that such discussions are entirely
confidential between you and your doctor. Your anesthesiologist's
only interest in these subjects is in learning enough about
your physical condition to provide you with the safest anesthesia
possible. So, in this case honesty is definitely the best
policy, and the safest one.
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What are the risks of anesthesia?
All operations and all anesthesia have some small risks,
and they are dependent upon many factors including the type
of surgery and the medical condition of the patient. Fortunately,
adverse events are very rare. Your anesthesiologist takes
precautions to prevent an accident from occurring just as
you do when driving a car or crossing the street.
The specific risks of anesthesia vary with the particular
procedure and the condition of the patient. You should ask
your anesthesiologist about any risks that may be associated
with your anesthesia.
To help anesthesiologists to provide the best and safest
patient care possible, national standards have been developed
by the American Society of Anesthesiologists to enhance
the safety and quality of anesthesia. Specific standards
already have been developed regarding patient care before
surgery, basic methods of monitoring patients during surgery,
patient care during recovery, and for conduction anesthesia
in obstetrics. New standards continue to be developed to
further ensure patient safety. These standards, along with
today's sophisticated monitoring and anesthesia equipment
as well as improved medications and techniques, have contributed
enormously toward making anesthesia safer than ever before.
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If I have an underlying medical problem, how will it
be handled during surgery?
Frequently, people requiring surgery may also have some
underlying condition such as diabetes, asthma, heart problems,
arthritis or others. Having taken your medical history prior
to the operation, your anesthesiologist has been alerted
and will be well prepared to treat such conditions during
surgery and immediately after. As doctors, anesthesiologists
are uniquely suited to treat not only sudden medical problems
related to surgery itself, but also the chronic conditions
that may need attention during the procedure, because their
medical training involves a firm grounding in the principles
of internal medicine and critical care.
Why are patients not allowed to eat or drink anything
before surgery?
For most procedures it is necessary for you to have an empty
stomach so that the chances of regurgitating any undigested
food or liquids is greatly reduced. Some anesthetics suspend
your normal reflexes so that your body's automatic defenses
may not be working. For example, your lungs normally are
protected from objects, such as undigested food, from entering
them. However, this natural protection does not occur while
you are anesthetized. So for your safety you may be told
to fast (no food or liquids) before surgery. Your doctor
will tell you specifically whether you can or cannot eat
and drink and for how long. In addition, the anesthesiologist
may instruct you to take certain medications with a little
water during your fasting time. For your own safety, it
is very important that you follow these instructions carefully
about fasting and medications; if not it may be necessary
to postpone surgery.
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Monitors: Tools of Vigilance
Microchips, finger cuff sensors, memory banks, tiny electrodes,
glowing displays and thermometers made of liquid crystal
are just some of the equipment anesthesiologists can use
to monitor a patient's progress during and after surgery.
Second by second observation of even the slightest changes
in a wide range of body functions give anesthesiologists
an extraordinary amount of information about a patient's
well-being. Monitoring is one of the important roles anesthesiologists
handle in the course of surgery.
Anesthesia Yesterday
Before the discovery of anesthesia over a century ago, relatively
little surgery could be performed Even a condition like
appendicitis, which by current standards is easily treated,
was usually fatal in those days.
What eventually evolved into anesthesia as we know it today
was ushered in with the chance observation that the inhalation
of nitrous oxide ("laughing gas") produced a state
of intoxication during which people became highly amused
and insensitive to pain. Many of the earliest demonstrations
of these effects were done for fun rather than science.
Traveling entertainers would organize "ether frolics"
in public halls, during which volunteers were invited to
inhale the mysterious substance, with results that were
considered amusing by the audience.
Some brilliant medical observers began to realize something
very important was happening. In 1842, Dr. Crawford Long
of Georgia used ether to perform the first painless surgery.
Dr. Horace Wells demonstrated painless dentistry under nitrous
oxide in 1844. In 1846, William Morton astonished doctors
at Massachusetts General Hospital when he achieved anesthesia
with ether. The new science of anesthesiology began to spread
around the world. After World War II ended in 1945, major
developments in the field of anesthesiology opened new avenues
of medical and surgical care that were previously unthinkable.
Thus began the modern era of anesthesia, which has advanced
enormously, especially in the last two decades. (Pictures
courtesy of Massachusetts General Hospital Archives.)
Please feel free to direct any questions or express any
of your concerns to your anesthesiologist. Your anesthesiologist
wants to make your outpatient surgical and anesthetic experience
as safe and pleasant as possible.
Copyright 1994 American Society of Anesthesiologists.
All Rights Reserved.
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