ON Friday morning, October 16, 1846, William Morton appears in the operating theatre of the Massachusetts General Hospital. Surgeon John Collins Warren is to remove a tumour from Gilbert Abbot’s jaw. For about three minutes, Abbot breathes a vapour from Morton’s simple apparatus. As Warren noted later, Abbott, “sank into a state of insensibility”, he “did not experience any pain at the time…”

This was the first successful public demonstration of “anaesthesia” as we know it today. The origins of anaesthesia can be traced to as early as the 18th century, however, it wasn’t until the 19th century that a change in cultural and social beliefs, coupled with scientific discovery, heralded the idea of “painless surgery”.

Indeed, the very term anaesthesia is based on its Greek origin, meaning “without sensation” and its introduction made it increasingly possible to save lives that were being lost to conditions and diseases through surgical procedures which before, were often hindered by the excruciating pain it brought to patients.

Earlier anaesthetics used were substances known as ether and chloroform. These were dripped onto gauze, which was then held over the patient’s face. Now, fast-forward to the 21st century, the modern specialty and practice of anaesthesia has come a long way from its painful beginnings, with many new advances.

Who is a physician anaesthetist?

To the public, we are oftentimes referred to as “the people who put patients to sleep and wake them back up”. However, we are, in addition to that, medical doctors (five years training and an additional two years apprenticeship in Jamaica), who have also completed postgraduate specialist training (four years in Jamaica) in the field of anaesthesia, which may or may not include training in the field of intensive care as well.

In Jamaica, a physician anaesthetist is trained in both areas. During our tenure, we receive training in the following areas:

• Paediatric anaesthesia (anaesthesia for children)

• Obstetric anaesthesia (anaesthesia/analgesia for pregnant patients)

• Geriatric anaesthesia (anaesthesia for elderly patients)

• Cardiac anaesthesia (anaesthesia for patients who require open-heart surgery)

• Neuro-anaesthesia (anaesthesia for patients who require brain or spine surgery)

• Pain medicine

Some physician anaesthestists, after completion of their postgraduate training, go on to further training in areas of specific interests they may have. The foundation of safe anaesthesia is the high level of training which underpins the specialty.

Additionally, in Jamaica, nurse anaesthetists also deliver some types of anaesthesia. These are nurses who have completed an accredited nurse anaesthesia training programme. They are also a key component of the anaesthesia care team (which includes physician anaesthetists, nurse anaesthetists and anaesthetic technicians) and are frequently supervised by physician anaesthetists.

What do physician anaesthetists do?

The skills of an anaesthetist are used in all aspects of patient care. The core of the work done, however, centres around ensuring the safety and well-being of patients undergoing surgery.

This requires an extensive knowledge base about medical conditions, medications and their effects, how the body works, and its response to stress as well as operating sophisticated and complex equipment. We carefully evaluate/assess and consider both the patient’s current state of health and the surgical procedure planned. This allows us to discuss our concerns with the patient and then devise what we believe to be the safest anaesthetic plan for them.

If the patient is sick and could be made healthier, then the operation (if it is an elective procedure vs an emergency) may be postponed to allow “optimisation” of the patient’s medical condition. This reduces the potential risk to which a patient may be exposed.

We are capable of delivering anaesthesia for simple to complex surgical procedures in patients of all ages, from the premature newborn, to the elderly.

Anaesthetists play a central role in the operating theatre, making decisions to protect and regulate your critical life functions. We are typically the first to diagnose and treat any medical problems that may arise during your surgery. Once the patient has entered the operating theatre, we are monitoring their vital functions such as heart rhythm, blood pressure, the amount of oxygen in blood, and temperature (as needed). If it is that the patient is to be put to sleep (general anaesthesia), then, in addition to the above, the anaesthetist monitors the level of consciousness, and each breath taken. More advanced monitoring may be employed depending on the type of surgery.

It is important to mention that once the patient enters the operating room, a trained professional is always by their side. They are never left alone.

At the end of the procedure, it is our goal to ensure that our patients emerge or wake up from surgery safely and pain-free.

We follow them as they recover from the residual effects of anaesthesia and their surgery, after which trained nurses in a recovery room setting then take over their care until they are ready to be discharged to the ward, after review by the anaesthetist.

If it is that we expect that they will require prolonged care after their surgery, then these patients may be admitted to a high-dependency unit or an intensive care unit.

What are the different ways of delivering an anaesthetic?

These include: General, regional, local and sedation.

General anaesthesia

This is a state of controlled unconsciousness during which time the patient feels nothing. This is the type our patients are oftentimes most concerned and anxious about.

Some surgical procedures, however, can only be done with a patient receiving a general anaesthetic. This is achieved by injecting medication into a vein or by breathing anaesthetic gases into the lungs (often used in children). These medications are carried to your brain where they lead to the state of anaesthesia (where you become unconscious).

Importantly, as the anaesthetic drug wears off, consciousness will return. Now, not all anaesthesia makes you unconscious.

Regional/local anaesthesia

Both of these techniques target specific parts of the body. Drugs used to cause this type of anaesthesia work by blocking signals as it passes along specific nerves to the brain. Thus, only causing a numbing effect to a portion of the body.

Once they start wearing off you are once again able to appreciate “sensation”. It is used increasingly frequently to avoid possible side effects of general anaesthesia, and can also be used in patients who are too frail to undergo a general anaesthetic.

A regional anaesthetic occurs when local anaesthetic drugs are injected near to the bundles of nerves which carry signals from that area of the body to the brain. The most common regional anaesthetics (or ‘blocks’) are spinal and epidural anaesthetics (often used in our obstetric or pregnant patients and oftentimes also for patients coming for orthopaedic procedures). You can again remain conscious, but free from pain.

A local anaesthetic numbs a small part of your body. It is used when the nerves can easily be reached by drops, sprays, ointments, or injections. You can remain conscious for the procedure, but of course free from pain.

Sedation

Oftentimes, in an attempt to make our patients more comfortable by attempting to relieve anxiety or pain during their procedures, we will administer sedative (sleep-inducing) medications. This method is oftentimes used to complement regional anaesthesia.

Talk to your anaesthetist

As is expected, many persons are apprehensive about undergoing surgery and, by extension, receiving an anaesthetic. However, I have found that patients who are well informed and know what to expect are better prepared and more relaxed.

We encourage open communication. So, talk to us. Ask questions. Express your concerns. Your anaesthetist is not only your advocate, but also the physician uniquely qualified and experienced to make your surgery and recovery as safe and comfortable as possible.

Finally, central to everything the anaesthetist does is patient safety, and this allows us to bring our patients safely through the most challenging operations. It is truly a rewarding experience.

Dr Deborah Douglas is an anaesthetist and chief resident in the Department of Anaesthesia and Intensive Care at the University Hospital of the West Indies, Mona.