No one died… Anaesthesia into the future

Anaesthesia monitoring into the future

When I first started learning about anaesthesia I was worried about if the patient would wake up or even survive the surgery. I was thinking about this today and realised that my thinking about anaesthesia has evolved since then. It used to be that I was grateful no one died when I was doing anaesthesia as that would be bad, I would have failed, and it would have taken a life because of my failure.

Today however I realised that it is not just enough that my patient survives any longer; it is how they survive that is more important. It is the quality of the anaesthesia, the maintenance of the depth of anaesthesia and the quality of the recovery from anaesthesia. All of these can be managed with an understanding of physiology, the effects of drugs, and with the correct monitoring. There are specialists in anaesthesia and whilst previously they mainly resided within universities there are many that are moving to private practices and referral hospitals. This means that the quality of anaesthesia is increasing – and in some places is done by specialists that only do anaesthesia which allows a higher standard to be provided.

Something that has always been a big problem here in Slovakia is maintaining temperature as the heating in the hospital is not great, the weather regularly drops below freezing in winter and we do not have warming blankets or systems apart from microwave heat pads which tend to go cold on a long surgery. In addition our monitor does not include an esophageal thermometer so we do not have any continuous monitoring of the body temperature once the patient is under drapes.

Once surgery finished instead of the recovery being as fast as it should the decreased body temperature and hypothermia increased the time that patients took to wake up. This was not so great for the patient however in terms for learning it was something that increased my experience and understanding of the physiology of the body system. It gave me experience in how quickly the temperature of an animal can change and the importance of body surface to volume ratio. Hopefully in the new surgical hospital now it will hopefully be less of a problem with new heating systems.

This is not the only factor that is important when it comes to anaesthesia, one of the things that I find important and I do not like to be without is a cannula which is an injection port into a vein. Normally I would also include fluids here at a low maintenance rate so that if I get problems I can then increase the fluid within the vascular system quickly in response.

It seems that things always come in bunches and so last week we had a few patients that had unwanted heart rhythms during their surgeries. Emergencies can and do occur and in this case from seeing the rhythm on the monitor it took just a minute to prepare the medications needed and get them into the patients because there was an IV cannula in place giving us access.

Thinking forwards I see anaesthesia becoming more about the big picture of pain management to ensure a smoother anaesthesia and recovery without the patient experiencing pain. And that is the entire point of anaesthesia – to allow operations without pain.

Is length the most important thing? (Day -160)

Quality vs Quantity of life in dogs

I’ve recently spent some time within some of the top oncology (cancer) referral vets within the UK and been in consults with people who have to be told that the biopsy says it is cancer. One of the most difficult questions that pet guardians will then ask is how long a loved pet has left – this is an awful question that has to be answered so carefully because we just do not know.

We try to use evidence based studies looking at different treatments when discussing the options – however these studies over use statistics to give averages. Unfortunately within veterinary research many studies only have a small amount of patients which is caused by the way the veterinary industry works. This means that when looking at a study with average life duration from start of treatment of 3 months that some dogs may have died at 1 week whilst others lived until 9 months or a year. I am personally starting to believe that statistics should be limited to use only in sample sizes over a defined minimum limit to improve reliability (I wrote about statistics here).

However what is missing from most of these studies is perhaps even more important and is the second question that most pet guardians ask. That is what the quality of life is like. It is something that may sound strange however it is much easier to quantify quantity of life (i.e. days) than it is quality (i.e. happiness) of a pet.

This is still something in it’s infancy within veterinary medicine – with humans we can explain that it will hurt now but it will mean that they are good later. The first time I saw this discussed was within surgery decision making in the AWSELVA journal in 2014 (J. Yeates & S. Corr) to evaluate treatment options based on the amount of painful time vs the amount of pain free time.

This is something that is difficult though as we need to define how we recognise the quality of life. For example if we consider movement as an indicator as recently there have been studies using accelerometers (step counters) to monitor the activity of an animal. A study just published used this to measure the physical activity in dogs receiving chemotherapy as an oncology treatment which may be acceptable.

However if we look at dogs with neurological problems that may have abnormal circling or pedalling movements then activity may not be the best quality of life. Here is where other techniques may come into play with things such as a seizure diary being kept to record frequency and duration of seizures to allow comparison of good time vs bad time.

Hopefully soon we will have better measures for the quality of life – and be able to apply these when making decisions that may impact animal welfare.

What doctors don’t want you to know… (Day -200)

What doctors do not want you to know

Growing up I always believed in doctors knowing everything. Actually it was more like doctors were not human being only doctors and living in the hospital and that was all they did. For me this applied the same to dentists. One time going to the dentist for a morning appointment, and the dentist arriving in their street clothes looking normal actually made me nervous about my treatment that day.

How could someone that looked so normal carry out treatment on my teeth?

I was thinking about this today whilst I was visiting the doctor at the human hospital for my rabies booster.

By thinking of doctors like this it is possible to remove the fear from the visit as doctors knowing everything would prevent anything going wrong. Actually I started to realise that it wasn’t just thinking of them as doctors, we start to elevate them to gods and miracle workers. We need that hope to protect us from the fear of what is going to happen as when we go to hospital we are vulnerable and not in control.

We need that doctor to be in control – and to do this we need to elevate them to a superhuman status. Where we will be safe under their care, where they will not make a mistake, where they will fix any problem.  We need to do this to trust them with our life, especially when it comes to surgery where we are absolutely helpless.

I then realised the same thing happened when I put on my scrubs and step into clinic. Especially when things go wrong – people look at you and expect you to have an answer.

Even when you don’t have an answer you have the responsibility of finding one. Sometimes it is logic, sometimes it is common sense, a lot of the time it is having support there from others and then sometimes it’s a combination of all three.

I remember the first time I was in this position was a couple of years ago. It was lunchtime and I was alone in recovery with a patient that had just come out of surgery, and there was the patient from the previous surgery whose owner was sitting with them whilst they recovered. The next thing I know the owner is saying something (I didn’t understand Slovak back then) however looking at the dog I see the eyes are flicking side to side.

I’ve no clue why however the first thing I do is check the breathing and heart. I see there are no muscle tremors. I’d read about nystagmus which is the random movement of eyes side to side, I thought this may be nystagmus, however I did not know why this dog had just started showing this. However I didn’t think that the dog was going die in the next few moments and my recovering anaesthesia patient was stable so I decided I had time to run to the staff room to get a doctor.

It was only a few minutes, however it felt like eternity. I had no clue what I was dealing with, I was not sure if it was even nystagmus. It turned out that it was positional nystagmus from the anaesthesia drugs that only happened because the dog was laid on its side. Knowing that my book knowledge was a little bit correct didn’t take away the feeling that I had got really lucky.

It was the first time that I felt like an imposter. Since then I’ve learnt that it is not just me that feels like this. Apparently it is a very common feeling that doesn’t completely go. No matter how much you learn, there is always more to keep learning. The really scary thing here is when you have something that you try to find out more about to only learn that there is no answer.

This is where you just start to realise just how human doctors really are. That no one has all the answers. Then you start to realise that doctors can make mistakes.

Then you realise that they really are no different to you, they are only human, people. Maybe they have studied a lot, maybe they have worked for many years…

The white coat or scrubs is almost a protective barrier to remove the human element. Remove this and they really are just another person.