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.