by Robert A. Duke
Author’s Note: We are grateful to the physicians who contributed to this article under the condition of anonymity and the understanding that they “… obviously do not speak for PeaceHealth or their profession, but have the right to speak for themselves, and because they think an article such as this is a great service to patients.”
Robert Duke: Focusing on your surgeon may seem obvious when considering surgery, but another member of the surgical team may be more impactful on the success of your surgery: the anesthesiologist. A large part of the danger and success of surgery depends on anesthesia. To minimize the former and maximize the latter, you may want to prepare for a deep consultation with the anesthetizing physician, whom you will most likely first meet in pre-surgery preparation and may never see again.
Physicians: Circumstances where a patient might see more of his/her anesthesiologist after surgery are when the anesthesiologist is responsible for post-op pain management if an epidural anesthesia was used for lung or kidney removal, for example. The anesthesiologist would make rounds on the patient daily until the epidural is no longer needed.
Robert Duke: Your first and only anesthesia consultation usually occurs with this smiling stranger studying you over the foot of your hospital bed, an awkward situation for which most patients are unprepared. Anesthesia is a routine part of surgery, and, what, if anything, do you — a mere surgical patient — have to say about it? You may — or should — have a lot to say about anesthesia if you are to be a well-informed participant in your medical treatment.
Physicians: A patient should be able to get at least a phone consultation with an anesthesiologist before the day of surgery, if desired. Such patients are seen as overwhelmingly better educated, medically savvy and probably have years of experience with the medical establishment. The anesthesiologist who does your phone consult, though, may not be the one who performs the anesthetic on the day of surgery.
Some Surgeries Not Worth the Risk
Robert Duke: When I turned 80 years old in 2018, I vowed to myself to avoid hospitalization and surgery for the remainder of my life. I felt there was nothing to be gained that was worth the risk: the risk of infection with hospitalization and the risks of medical error and anesthesia with surgery. I had three spine surgeries — 2011, 2015 and 2016 — and decided none was successful and so not worth the inherent risk.
Physicians: Many people have recreational surgery. Some, who have back surgery for a diagnosis of back pain, would probably get the same results if they lost 30 pounds. Patients, even after hearing the potential risks of anesthesia, insist they have no choice, even if most back surgery is elective.
Robert Duke: Facing surgery for a recurring painful cyst, I chose outpatient surgery to avoid hospitalization, but, still facing anesthesia, I was intent on minimizing that risk if I could, which led to my first purposeful anesthesia consultation. It was prompted by the alarm raised by a box checked off on an outpatient surgical center brochure I received in the mail. Whoever mailed the brochure to me had checked off the box titled “General or Regional” under the category “Anesthesia Type” on the back cover of the folded brochure. The choice of general anesthesia for a cyst excision seemed excessive for what I considered a minor and superficial surgery. Were medical decisions being made for me by someone checking off a multiple-choice box on a promotional brochure, I worried?
Physicians: A reasonable worry, but such a checked-off box is not an end-decision; rather, it is to distinguish anesthesia from sedation only. It’s a planning guideline. Sometimes surgeons want general anesthesia, but the patient refuses and requests a spinal (or vice versa). Other times it is an issue of how the surgeon trained. If a patient is against a general anesthetic, say for carpal tunnel surgery, the patient can consider switching surgeons to one who can work around a pool of local anesthetic in the surgical area.
Robert Duke: I know little about anesthesia, but, in my mind, general anesthesia meant maximum anesthesia, and I knew I didn’t want any more anesthesia than necessary. Other brochure choices were “Local, with or without sedation” and “Managed Anesthesia Care (MAC).” From past experience, I thought there were probably other options not listed, such as “epidural.”
Physicians: There are sometimes anesthesia options. Some people are terrified of being awake in the operating room and some are equally terrified of being asleep. Some patients hear the word spinal and recoil. Other times, there really is no option.
Robert Duke: I never had a bad experience with general anesthesia, and I recovered from it quickly and without side effects, but, for me, it was the principle of it. Why take on the additional risk inherent in general anesthesia if it could be avoided? I should at least question the premeditated selection of general anesthesia if I were to be a prudent, responsible and involved patient.
As is routine, I didn’t meet my anesthesiologist until the day of the surgery, within an hour of the scheduled procedure. I explained to the anesthesiologist that, while I reacted well to past general anesthesia, I was no fan of having a tube shoved down my throat so I could be connected to a ventilator in order to breath while anesthetized and wondered whether another form of anesthesia was practical for the type of surgery that was planned. My anesthesiologist said there might be alternatives, but whether any were practical would depend on the surgeon’s requirements based on details of the procedure that was planned. When my surgeon arrived, she and the anesthesiologist discussed the pros and cons of various forms of anesthesia in the context of the intended surgical procedure and my condition as a patient (age, history, vital signs, etc.).
The conversation included me as a full participant in the discussion and proceeded to the conclusion that I would have a spinal anesthetic, which would meet the surgeon’s needs, satisfy the anesthesiologist’s requirements, and fulfill my desire to avoid the complexities of general anesthesia. I’ll let the physicians explain: Physicians:: A spinal anesthetic entailed injecting the anesthetic into the cerebrospinal fluid that surrounds the spinal cord. It was an epidural, which lasts as long as you need it to last, because, instead of a single injection of local anesthetic into the sack of cerebrospinal fluid, which wears off eventually, an epidural is placing a thin catheter into the epidural fat (surrounding the sack of cerebrospinal fluid), and more drug can be added for as long as the surgery takes.
Robert Duke: Anesthesiologists spend far more time with surgical patients in surgery than do surgeons. The surgeon arrives to do a procedure when the patient has been fully prepped and departs when the procedure is complete. The anesthesiologist shows up about an hour before surgery, accompanies the patient from pre-surgery prep into the operating room, preps the patient for anesthesia, anesthetizes the patient, monitors the patient’s condition throughout surgery and makes necessary adjustments, attends to the patient’s condition through recovery and sees the patient out of recovery and into general care when surgery is complete — hand holding from beginning to end.
Physicians: This is a matter of perspective. Surgeons, after all, meet the patient pre-op in the office and may see the patient daily as long as they are in the hospital; or at least that’s how things used to be. Now, not all surgeons do rounds on patients.
Robert Duke: My experience with anesthesia as a patient and caregiver spans a wide spectrum. When my late wife underwent a craniotomy to remove a fatal brain tumor, her anesthesia allowed her to be conscious during brain surgery to assist the surgeon for testing the boundaries between the tumor and normal brain tissue. (There are no pain receptors in the brain.)
When I had cervical spine surgery, to fuse together three vertebrae, it was the anesthesiologist who discovered my pre-surgery heart rate was an unacceptable 140 beats per minute (bpm). Surgery could not proceed unless my heart rate were reduced to 80 to 90 bpm. To my astonishment, the solution was to stop my heart momentarily to force it to reset its bpm, which was done with a cardiologist and a half dozen others standing by. Following a second attempt, my heart rate dropped to a normal 80 bpm and my surgery proceeded routinely. Such an experience made me extremely interested in knowing my anesthesiologist.
Robert Duke: For my cyst surgery, the discussion between the surgeon, anesthesiologist and me included the following:
• Posture of patient during surgery.
Physicians: If the patient needs to be face down for the surgery, and, if the repair will take three hours, a spinal may be fine if the patient is willing to lie on his/her belly that long, with his/her head turned to one side. If the patient were to want a spinal, but is obese and has obstructive sleep apnea, it might be dangerous.
• Types of access to anatomy based on area of surgery. (These are additional criteria for considering posture; see above.)
• Patient’s condition, history and current health.
Physicians: Profound lung or airway abnormalities may make the use of a spinal preferable, but, if a patient were on anticoagulants, a spinal (or epidural) is out of the question unless the anticoagulant has been withheld for several days. A patient with some degree of dementia might do best to avoid a general anesthetic to avoid post-operative cognitive decline. Patients who get crippling post-operative nausea/vomiting may benefit from total intra-venous anesthesia (TIVA).
• Surgeon’s preferences — arbitrary practices, conveniences or choices. Physicians: See our comments above. n Post-op considerations influenced by anesthesia.
Physicians: Prime examples would be post-op cognitive decline, post-op nausea/vomiting, extreme sensitivity to opioids (in which case a spinal or epidural might help), and patients with chronic pain. Other patient’s post-op considerations are their ability and willingness to cooperate.
Americans have come to believe that it is possible to have surgery (or a baby) pain free, nausea free, hunger free, inconvenience free. It isn’t. If you are going to scream in pain with the intravenous (IV) placement, you need to reevaluate whether you really need to have the surgery. If you say you absolutely must be asleep for the surgery, but you cannot accept that you will have a sore throat from the breathing tube, then you need to be realistic. If you insist on a spinal, but cannot accept that you might have difficulty urinating for a few hours afterwards, then you need to be educated.
Robert Duke: What does it take to get to know your anesthesiologist? Nothing more, really, than an awareness on your part of the anesthesiologist’s role in your surgery and a desire to know as much as possible about the surgical process and procedure about to be centered upon you — the patient. Ask questions and insist on explanations until you feel satisfied that you understand what you have agreed to and authorized to be done to you in the name of treatment and healing, of which anesthesia is a key component.
Physicians: We try, fairly unsuccessfully, to convince patients that one hires his/her doctors the way one hires other professional services. Shop around, ask around, and demand to be treated respectfully. Demand more. You have a choice.
Robert A. Duke is author of “Waking Up Dying: Caregiving When There Is No Tomorrow,” and lives in Bellingham. His email: firstname.lastname@example.org.