Erik is a 37-year-old barrister who is in the middle of preparing for a large and important court case. He works long hours, eats irregularly, and has had long-standing problems with bowel function. He finally went to see a surgeon with whom he plays squash. The surgeon examined Erik and determined that he needed to have a haemorrhoidectomy.
Erik says, “I really didn’t like the idea but I couldn’t go on as I was, with the pain and bleeding, particularly with this case coming up. The surgeon reassured me that I’d be out of hospital the next day and back into my office the day after.”
At the hospital
It is now the day of Erik‘s operation. He has been instructed to be at the hospital at seven o’clock in the morning, in preparation for his operation at eleven. He decides that he should call at the office on the way and arrives at the hospital, at a quarter past nine.
“Still plenty of time before 11 o’clock.” he thinks to himself.
“Where have you been?” asks the nurse, when Erik arrives from Admission half an hour later.
“I’m not sure that’s any of your business,” replies Erik. “My operation is not until eleven, there’s over an hour to go.”
“Well, it’s just that there are a lot of things to do to make sure everything is organised. We began to think that you had cancelled. Your anaesthetist was here at half-past seven to see you and now he’s in the middle of the operating list.”
“Couldn’t he come up after he’s put the other patient to sleep?”
“He stays with each patient until the operation is finished and the patient is in the recovery room. He’ll obviously need to tell you quite a bit about anaesthesia.”
“Is that how they justify their huge bills – sitting down and reading the paper while the surgeon does all the work?”
“No – I mean, what they charge is their affair, but the anaesthetist is certainly not reading the paper during the operation. It’s their job to watch you and everything about you. Your life depends on your anaesthetist!”
“Oh well, what now,… where do I go? Let’s get it over with.”
The nurse shows Erik to his room, which has only one bed and an en suite bathroom. Erik is prepared to pay the extra cost so that he doesn’t have to share a room with other patients.
She instructs Erik on the use of the electronic bed, the television set, and call button. She then directs him to get undressed and to put on a hospital gown.
Erik is impatient but takes note.
“The operation will be at eleven, won’t it?”
“That’s when it’s scheduled, but it may not be on the dot of eleven. It depends very much on how the previous operations go, whether there are any complications, and so on. Patients are not like Swiss trains, you know!”
Erik grunts acknowledgment. He puts on the hospital gown and his own dressing gown over it, and opens his briefcase to retrieve a folder of papers.
Not long after, Dr. Alexander, the anaesthetist, knocks and enters the room.
“Hello, I’m James Alexander, your anaesthetist,” he says, extending his hand. “You must be Erik.”
“That’s right – who’s looking after your patient?”
“Excuse me?” enquires Dr. Alexander.
“I thought you were busy in the Operating Room – at least that’s what the nurse said.”
“Oh, we finished a little sooner than expected, so I popped up to see you while the surgeon dictates some notes.”
“He’s very busy. I understand he’s the best in the business.
“Yes, he’s very good,” replies Dr. Alexander. “Now, about your anaesthetic.”
“Just a quick injection and it should all be over – I’m preparing for a major brief for next week and I need to be on the ball again this afternoon,” says Erik rather brusquely.
“Well, it’s not quite that simple.” Dr. Alexander replies In a patient tone, “You’re likely to be in a lot of pain after this operation. So one way we could manage that is with a spinal anaesthetic – which wouldn’t make you sleepy afterwards.”
“I don’t fancy a spinal,” responds Erik. “I remember one of the senior partners had a case of paralysis after a spinal anaesthetic.”
“How long ago was that?”
“Oh, not really sure, maybe fifteen, twenty years ago. That partner has pretty well retired, just comes in for a drink and a chat now and again. Still got him on the books though, QC and all, looks good for the company. But he always likes to talk about the case – how he tore into the anaesthetist on the stand.”
“Yes, I’m sure he recounts the story well,” says Dr. Alexander rather dryly. “There have been a very small number of cases of paralysis or permanent nerve damage after spinal anaesthesia – more often talked about than occur. Nevertheless, it is a major complication which has to be considered, although the possibility of major nerve damage after spinal anaesthesia is about the same as the possibility of brain damage after general anaesthesia – extremely rare.”
“Well, what about a general anaesthetic – don’t they wear off quickly these days?”
“Yes, they certainly wear off more quickly than they used to, but even with the shortest-acting drugs there is some hangover effect and there’s also the hangover effect of any narcotics given for pain relief in the Recovery Room. You probably wouldn’t be able to concentrate fully for a day or two. Whatever the case, after a haemorrhoidectomy, you’ll need to be taking something for pain for the next few days and that will affect your mental function a little.”
Momentarily lost for words, Erik reaches over and snaps his briefcase shut and then looks back to Dr. Alexander.
“Well, I suppose I don’t have much choice, what with this case next week, and then I’m heading overseas for three weeks for a holiday. I want it fixed up before that.”
“My recommendation is for you to have a spinal. I’ve personally never had any complications and have probably done a couple of thousand, although I cannot promise that a complication will not occur. I can only do my best. But spinals work very well and I can do two things to try to help your particular situation. First, I’ll add some narcotic to the local anaesthetic mixture. That should give you some better pain relief. Might even work for 24 hours. And second, I won’t give you any sedation in the Operating Room, unless I think that you’re getting too distressed. But then, you’ll have to put up with the noise and the clatter, plus having your legs up in stirrups for forty minutes or so. You won’t be able to see anything, though, as I’ll put up a screen.”
Erik wrinkles his nose and looks thoughtful, but says nothing.
“Now, I’ll need to start an intravenous – you’re right-handed, aren’t you?”
“Yes, yes I am.”
“I’ll put the intravenous into your left arm so you’ll be able to use a pen when you get back here to your room. But if I end up giving you some sedation, then I recommend that you don’t work – these are powerful drugs and I would hate you to send someone to jail because you couldn’t concentrate on your paperwork.”
In response, Erik lifts an eyebrow. “Any other complications I should know about?”
“The other major complications include areas of numbness or changed sensation that might rarely occur if the needle hits and damages a small nerve near the spinal cord. That’s not likely to happen, as you’ll be awake when I put the needle in. If it touches a nerve, you’ll be able to tell straight away.”
“Does that hurt?”
“It’s not so much pain as the sensation you get when you hit your funny bone.”
“Anything else?” asks Erik.
“Apart from that, there have been reports of toxicity to the nerves from certain local anaesthetic agents, but I don’t use any of those. In addition, there is always the possibility of infection that could lead to meningitis. However, I’ll be using full sterile technique. All the equipment is single-use, disposable, and I’ve never seen it happen. You could also get phlebitis, or inflammation from the intravenous, but the IV won’t be in long, and again I’ll be using sterile technique to start it. Of course, you also have to recognise the possibility of complications from the operation, which, no doubt, your surgeon has fully explained to you.”
“Er,” responds Erik, now visibly paler, “perhaps you could just remind me of them.”
“The general surgical complications include bleeding, infection, and failure of the operation to relieve the problem. Then there are the complications from the positioning for the operation. In your case, your legs will be up in stirrups, with your legs bent at the hips and knees. So there’s always a possibility of blood clots in the legs and nerve damage. The first is unlikely as you’ll be up and about fairly soon. The nerve damage is something we all take particular care to avoid by padding all the possible pressure areas. This includes not just your legs but also your arms. Do you ever wake up in the morning with a numb arm or fingers?”
“Why yes, sometimes this left arm is just like a piece of wood, then it hurts like the devil when the sensation returns.”
“That means that you’re more likely to develop nerve compression damage than someone who doesn’t get this. So we’ll pad you well. But it’s another reason to remain awake – that way, if your arms are a bit uncomfortable, you can wiggle them about.”
“What if the spinal doesn’t work?”
“There’s always general anaesthesia to fall back on”.
“And what are the complications of general anaesthesia?”
“If we take the serious complications first, either death or permanent brain damage.”
“That’s not very encouraging – I thought you anaesthetists were supposed to be looking after patients during the operation.”
“We are, and I will be, from the beginning until after the operation, when I’m absolutely satisfied that you are safely recovering from the anaesthetic.”
“So how could I die, then?”
“From the anaesthetic – if you had an unforeseen reaction, say to a drug, and we couldn’t save you, or if you had a heart attack during or after the operation. You could also die if there was a problem with your breathing, which we were unable to deal with. Of course, there’s also the possibility of the surgeon puncturing a large blood vessel causing catastrophic haemorrhage.”
“A heart attack, why should I have a heart attack?”
“Heart attacks occasionally occur in young people in stressful situations without warning. But remember, I’m talking extremely rare occurrences here. From what I can tell about you – from what I’ve read in the notes and looking at you now – there’s no reason to suggest that it would occur. I’m simply giving you full information about serious but very rare complications, so that you can make a choice.”
Dr. Alexander continues, “And as for drug reactions…”
“You mean allergies?” interrupts Erik. “Wouldn’t I know if I was allergic to something?”
“There are two kinds of reactions. The more common one is allergy, and no, you wouldn’t necessarily know that you were allergic to any of the anaesthetic agents. Sometimes the reaction can occur out of the blue. The other kind of reaction is related to a genetic predisposition. The most serious condition is called malignant hyperthermia or MH. A very, very few families carry a gene that predisposes the patient to react to two particular types of anaesthetic agents. If those patients react, their muscles stiffen and they develop a very high fever. Without a special drug treatment, they have a 50% chance of dying. But it’s so rare that we’ve never seen a case in this hospital, and we give about 20,000 anaesthetics each year.” Dr. Alexander continues, “Now, you do need to realise that I know how to recognise and treat all of these complications. It’s part of anaesthetic training and we keep up-to-date, learning about new reactions and new treatments.”
“That’s quite reassuring,” admits Erik.
Just then, the nurse enters the room.
“They’re calling for you in the Operating Room. Do you want to walk down with Dr. Alexander and me? They must be running a little late – it’s 11:20.”
“Why don’t we all go together?” asks Dr Alexander.
He turns to Erik, “Now are you comfortable with all I’ve told you? Is there anything else you wish to know?”.
“Yes, I’m comfortable. No, I don’t want to ask anything. Let’s just get on with it.”
On entering the Operating Room, Erik is asked to sit on the operating table, with his feet over the edge and resting on a high metal stool. The assistant attaches all the necessary monitors and helps Dr. Alexander to start an intravenous line. Dr. Alexander then asks the assistant to wrap a warm sheet around Erik’s shoulders and to support Erik in bending over.
To Erik he says, “I’d like you to stay nice and still while I scrub up. It will only take a few minutes.”
Having done so, Dr. Alexander prepares the area on Erik’s back where the needle will be inserted.
“You should feel only a slight pin-prick and then a bit of dull pushing.”
Erik grunts in response.
He then takes a very fine needle and places it through the skin in the middle of Erik’s lower back.
“That’s fine. Now hold very still while I inject the drug mixture. Is that OK?”
“Yes,” says Erik in a quiet voice.
“Good, all done,” says Dr. Alexander. “Now we’ll just have you sit there for a minute, to get most of the drug around your bottom.”
Erik notices that his feet and legs become warm and then very heavy.
Just then, Dr. Alexander says, “Right, we’ll have you lie back down on the operating table.”
After the anaesthetic
Later that afternoon, Dr. Alexander knocks on the door of Erik’s room and enters. He finds Erik reclining in bed with his head propped up and a large number of open folders and papers scattered about.
“How are you feeling, Erik?” he asks.
“Apart from the strange feeling in my legs, I’m fine – really good. Not having any sedation wasn’t so bad after all. I’ve had some water and a piece of toast and I’m looking forward to dinner.”
“Great! Any problems?”
“Well, I had a bit of trouble having a pee, but that seems to be OK now – no, everything’s fine.”
“You’re happy to stay until morning?”
“Yes, I’ve sorted out the office and I’ve got all my papers here – and there are no phone interruptions. Mind you, I’ll be out of here first thing tomorrow!”
“Good. Get the nurses to call me if there is anything worrying you.”
“I will…. and thank you.”