ANESTHESIA – THE WONDERS WE CREATED AND THE POTHOLES WE DUG

The Tombstone in the Boston Cemetery marks the site of the “Inventor and Revealer of Inhalation Anesthesia: Before Whom, in All Time, Surgery was Agony; By Whom Pain in Surgery was Averted and Annulled; Since Whom, Science has Control of Pain.”

The demonstration of Ether’s effect occurred in a Boston Hospital in October 1846.⁴ One of the nation’s most active, Boston’s Mass General Hospital was, at the time, hosting up to two surgeries a week. They were performed in an operating room that was, in essence, a stage. It was surrounded by a steep amphitheater. People filled the seats and watched. One October day the doctor in charge, Dr. Warren told the onlookers “there is a gentleman who claims his inhalation will make a person insensitive to pain. I decided to permit him to perform his experiment.”

The dentist who administered the anesthetic, Dr. Morton, was described as being strikingly attractive and alternately optimistic and pessimistic.” He arrived 25 minutes late, took out his narrow neck flask, and filled its bottom with two liquids: Sulfuric ether and oil of orange. The second chemical was supposed to mask the ether odor.

The man who was about to undergo surgery inhaled “gas” through a mouth piece, and in 3 to 4 minutes he became “insensible and fell into a deep sleep.” He had a mass in his neck and the doctor quickly cut it out. When the operation ended Dr. Warren, the man’s surgeon, spoke to the rapt onlookers. Gentlemen, this is no humbug. People cheered, and the public took notice.²⁶

During the Civil War battle of Fredericksburg, Morton decided to help. When a wounded soldier was about to undergo a limb amputation Warren “prepared the man for the knife, producing perfect anesthesia in an average time of three minutes.⁹”

Once operations could be performed without pain surgeons started performing them and a number of hospitals were built or expanded. Elective surgery became the cash cow that supported one institution after another.

In July 1868 William Morton was agitated because another doctor was trying to claim credit for his invention. He was in New York, the city was in the midst of a grueling heat wave, and Morton took his wife on a wild carriage ride through Central Park. Then he abruptly stopped the buggy, got out, and died. He was 48 years old.⁵

One hundred years to the month later I was asked to see a sick patient with jaundice. At the time I was the assistant chief medical resident at the San Francisco VA hospital, a collection of buildings on the edge of the Pacific that were usually blanketed in fog and cooled by a breeze from the ocean. The man I examined had yellow eyes, was weak, had no appetite and was lying in his bed. He recently had a hair transplant and otherwise had been well. He’d been put to sleep with halothane, the anesthesia of the day. Plugs of his hair were harvested from the back of his head, and planted up front.

The patient told me this had been his second transplant. He turned yellow the first time and thought he knew what was happening. He had witnessed fellow service men that got hepatitis when he was stationed in the South Pacific. He decided to not tell his doctor because he was afraid the physician wouldn’t perform the second set of hair transfers.

This was a few years before liver transplants were being done, so people with failing livers could not be rescued. The patient’s condition got worse, his abdomen filled with fluid, he sank into a coma, and he died. — And it happened because of a hair transplant.

Most anesthesiologists back then didn’t believe “so called” halothane hepatitis was a real entity and wouldn’t accept that the anesthetic they used could cause the problem. They had “never seen” a case of liver failure they couldn’t pin on one of their patient’s underlying conditions. Halothane was a smooth, well tolerated anesthetic. I was a budding gastroenterologist and I knew they were wrong. Turns out that halothane causes liver failure and death in one of 35,000 patients. Anesthesiologists needed proof and they got it in 1969 after an MD anesthesiologist visited the Yale hepatologist, Gerald Klatskin. The doctor said he turned yellow every time he administered halothane to a patient. Klatskin decided to test his theory. He biopsied the doctor’s liver. It was normal. Then the anesthesiologist inhaled halothane and his eyes and skin turned yellow. A second biopsy showed an injured liver. Klatskin published a report of the case, and U.S. anesthesiologists stopped administering halothane. It is still “widely used in developing countries.³”

Fast forward 40 years and I’m interviewing the chief of anesthesia at a local hospital. He’s telling that nowadays general anesthesia is safer than crossing the street. During the 50 years when the rest of medicine was inventing new operations and trying to cure more diseases, the top anesthesia thinkers were obsessed with safety.

They’d long since learned how to put a person into a state where the patient heard and saw nothing, was impervious to pain, and had muscles that were totally relaxed. When aroused some people had painful wounds, sensitive areas, inactive bowels, and bodily parts that didn’t function normally. Grogginess could last a while. But the recipients of general anesthesia had no memory of the trauma their body had endured. Doctors and dentists used diethyl ether and later chloroform as early as the mid and late 1840s. Over the decades drugs changed, but the overall effect has largely remained the same. One of the current anesthetics of choice is propofol, the drug that killed Michael Jackson. It’s administered as an intravenous drip. It starts and stops working rapidly and has a “low incidence of side effects such as postoperative nausea and vomiting and cognitive impairment.¹ ”

Some operations are routinely performed using spinal anesthesia, a nerve block or a local infusion of lidocaine.

In addition to physicians, 43,000 nurses administer much of the anesthesia in this country. These nurses are educated, trained, licensed, and competent. In all but 15 states they are required to “work under a physician’s supervision”.

The anesthesiologist whose insights I’m channeling credits the emphasis on safety to the skyrocketing cost of malpractice insurance. It became the focus of a number of physicians who “passed gas” for a living in the 1980s. I’m sure doctors in the field thought their care was excellent and wondered why they were being singled out. But the numbers said it all. In 1974 three percent of all American doctors who bought malpractice insurance were anesthesiologists, and these were the very doctors who were responsible for 10% of all malpractice pay outs. Outsiders concluded that the care they provided was “below the standard”.

Malpractice is not a good way to judge medical quality. Doctors are sued when something major goes wrong and when the responsible physician is arrogant or seems to be hiding something. It’s also is easier to sue someone you have never consciously spoken to or interacted with, someone who has never become a real person with feelings and regrets.

Nonetheless rates were rising and something had to be done. The anesthesia societies embarked on something they called the “closed claim project.” They reviewed malpractice suits that had run their course, that had been litigated, settled or just dropped by the plaintiff. Discovering what went wrong did not create a legal or other risk for the involved doctor.

Data for events prior to 1990 revealed that in a third of the cases, the person whose families sued had died or had suffered brain damage. In 45 percent of these people the harm was caused by a “respiratory event”. When anesthesiologists induce coma they become responsible for the movement of air into and out of the lungs. They slide a tube through the mouth and pharynx, between the vocal cords, and into the bronchus. Then they aerate the lungs and the body. In 7 percent of the respiratory cases the anesthesiologist mistakenly slipped the breathing tube into the esophagus, the tube that transports food and drink to the intestinal system. It is located above the vocal chords at the lower end of pharynx. A sphincter at its top end keeps air from entering the gut and helps prevent regurgitation of esophageal contents.

In 12 percent intubation was difficult, and the body was deprived of air for a period of time. In another 7 percent the doctor got the tube in the right place but didn’t ventilate the lungs adequately.

25% of the law suits were the result of cardiovascular events, arrhythmias of the heart, a drop in blood pressure, and heart attacks.

Nerve damage due to poor positioning and compression of nerves caused 21 percent of the problems.

Anesthesiologists sometimes instill Novocain or alcohol into nerves in an attempt to mitigate chronic pain. If they injected a person who was taking blood thinners they sometimes precipitated bleeding; damage caused by the leaking blood prompted some of the legal action.

6% of the cases were prompted by burns caused by electrical cautery or by IV bags of fluid that were overly warmed.

There were people whose drop in blood pressure resulted in a loss of vision, individuals whose airways had been damaged during a difficult intubation, and a few who had back pain, emotional distress, or eye injuries. (Anesthesiologists work close to the eyes.)

79% of the problems were attributed to lack of vigilance. The specialty’s has an old saying: putting someone to sleep starts with seconds of panic, (intubation) and is followed by hours of boredom.

After the anesthesiologists learned what they were doing wrong they disseminated their findings, made recommendations, and general anesthesia became safer.

Anesthesiologists now have tools that make it possible to intubate almost everyone. Small flexible instruments containing long fiberoptic bundles, allow the anesthesiologist to see into dark corners. Some scopes have chips on their tips and send images to a TV screen. Anesthesiologists and anesthetists confirm the endotracheal tube is in the right place with a beside ultrasound examination and by measuring and monitoring the carbon dioxide level of air that exits the lungs. If the level gets too high ventilation may be inadequate. Since the blood of anesthetized people is enriched with oxygen, a high carbon dioxide concentration is more sensitive than low level of oxygen as an indicator of air movement problems. Complex machines that ventilate the patient regulate and monitor the movement of the gases. Sophisticated gear has valves and gauges that are routinely checked. Bells ring and beeps sound when something is amiss.