Will I Wake Up During My Operation?

This is a major concern for many patients who have an impending date for surgery. It seems to be a primal fear, lying there, unable to speak, unable to move, in pain. But is it going to happen? A golden rule in medicine is that nothing ever ‘never’ happens, but it’s very unlikely. ‘Awareness’ is reported in 1 in 19000 anaesthetics. But the idea of it is terrifying, isn’t it?

There was even a film!

It’s made the news because of the NAP 5 audit. This is a ginormous study involving every public hospital in the UK, looking for incidences of AAGA – accidental awareness during general anaesthesia, undertaken by the Royal College of Anaesthetists (RCoA) with the Association of Anaesthetists of Great Britain and Ireland (AAGBI). It’s commendable that the speciality would examine itself in this open and honest way.

Awareness. It’s a broad term. It could be someone who remembered their breathing tube coming out at the end of an operation, it could be someone who remembered something happening whilst they were sedated (and not supposed to be completely unconscious). It could be someone who was not adequately sedated when being moved from the operating theatre to the intensive care. In the study, awareness was most likely to occur when just going to sleep (induction) or when being woken up at the end of the operation (emergence) rather than in the middle of operations.

To get your head round the results, it might help to know a bit about anaesthesia itself. Skip this bit if you’ve ever given one.

Anaesthesia is an oft-misunderstood medical speciality. I think we should remember the incredible contribution that advances in anaesthesia have made to the world. Surgery that was once either completely intolerable or technically impossible is now performed safely and regularly. However, when I started my training (I only did 18 months before changing specialty) I was asked if I was still a doctor!

It has been compared to being an airline pilot, where all the action’s in taking off and landing and you can just kick back for the middle bit. Like being a pilot, you need to be trained for the worst-case scenarios. Unlike it, emergencies arise frequently. During the operation, it might look like the anaesthetist is not doing much, but they are monitoring, adjusting gas flows, giving antibiotics, analgesia and planning the next phase of the procedure. They have to constantly modify their techniques depending on how the operation is going or the patient is doing. But what is ‘an anaesthetic’?

Anaesthesia can be local – you cut yourself and need stitches and the A&E doctor injects some local anaesthetic (LA) to numb the immediate area. Many minor operations in operating theatres happen under LA alone, without an anaesthetist present.

A surgeon or anaesthetist may administer regional anaesthesia by targeting one or a group of nerves to numb a larger area, for example in foot surgery. This can occur alone, or in combination with a general anaesthetic.

A neuraxial block may be used – an injection into the space around the spinal cord will numb everything from the waist down and is handy for knee surgery etc. An epidural works in a similar way. These are often used in combination with sedation, where consciousness is reduced with medication, but the patient is not fully anaesthetised.

A general anaesthetic (GA) is where a patient is given medications to render them unconscious. This usually starts in the anaesthetic room and involves several stages:

1)            Induction – Drugs are given, usually straight into a vein, to temporarily render them unconscious. Once this happens, the patient can no longer protect their airway and a device is inserted to keep it open and allow the delivery of oxygen and anaesthetic gases later. If a breathing tube is to be inserted, then the patient must be paralysed, to relax all the muscles in the mouth and throat and allow the tube to pass.

2)            Maintenance – The patient is transferred to the operating theatre and is kept asleep. This is usually with anaesthetic gases but can be with a continuous infusion of medicine into the vein. The patient may breathe for themselves, depending on the operation. For certain operations, such as abdominal procedures, continuous muscle relaxation is needed so the patient remains paralysed and the breathing is done by a ventilator.

3)            Emergence – Once the operation is finished, the anaesthetic gases are turned off and the patient starts to wake. If they have been paralysed, then a reversal agent is given first so their muscles can work again and they can breathe. Any artificial airway is removed and the patient can be taken for further monitoring in the recovery room.

There are many more ways to give an anaesthetic than to skin a cat, I would imagine. You have to consider the patient and the procedure. In some ways it’s a very scientific speciality, built as it is on the three P’s of physics, pharmacology and physiology but in others it’s an art. You can learn what the right anaesthetic is for a particular operation and the dose of a drug that the average patient of a particular size, sex, age and fitness will need, but it must be individualised and you must respond to all the information that is available. You might be watching the patient and two screens with many variables displayed whilst getting information from the surgeon and the rest of the team and administering five or even ten different drugs and vapours. Anaesthetists are very well trained but you can see how there are opportunities for error.

Why not just give more?

Fair question. Unfortunately, all the sleepy drugs have side effects. Probably most importantly effects on blood pressure. Also, the more you get, the worse you feel afterwards.

So what did the audit find? The headline figure is that AAGA is reported once for every 19000 anaesthetics. This means that you are more likely to be killed in a traffic accident in any single year than experience awareness during a single anaesthetic.

However, the chances very much depend on the type and technique used. When neuromuscular blockade is used (paralysis) then the incidence rises to 1:8000.

Why and when does awareness happen? Well, there are several reasons...

During the induction phase, the anaesthetist needs to secure the airway. This can be straightforward or take a little longer. The longer it takes, the more chance the patient has of becoming aware of what’s going on. They then need to be moved to the operating theatre and are not connected to the anaesthetic machine at this time.

During maintenance, there are a variety of ways that the anaesthetist determines whether enough anaesthetic is being delivered. Sometimes EEG brain monitoring is used. The anaesthetic machine may give a display of how much anaesthetic gas is being breathed out by the patient (a good approximation of how much is in the brain). Small rises in pulse rate might indicate that the patient is not ‘deep’ enough. Another is that a patient may cough on the airway device or move on the table. This is not to say that they are conscious, just that some primitive reflexes are being stimulated and the patient needs more anaesthetic. Neuromuscular blocking drugs prevent this movement and so take this valuable warning sign away.

As the patient wakes during the emergence phase after the op, if the neuromuscular blocking drug is not adequately reversed, it can be that the anaesthetic wares off before the paralysis. This could lead to awareness without being able to move. For emergency procedures, the patient must be more awake before the breathing tube is removed, to ensure that their airway is protected if they were to vomit. There is a chance that they could remember the tube coming out.

Particular operations are higher risk for AAGA as well – heart surgery and C-sections as different drug combinations are needed in these patients. Pregnancy poses many particular challenges to anaesthetists, due to altered body shape and physiology and the need to care for two patients.

The study makes particular mention of reducing drug errors and how institutions can change lists and practices to reduce avoidable errors.

I think the main thing to pick out is that awareness is rare but not absent. When it occurs it can cause significant psychological harm. Awareness includes many experiences that are not 'waking up in the middle of the operation'. But the report is positive in that in identifies many ways in that the risks can be reduced. So things will get better.

So will you wake up during your operation? It’s extremely unlikely and will become even less so.

Podcast Episode 1 - eCigarettes, Scottish Independence and the NFL!

In our first podcast, Dave and I talk eCigs and eCars, Scottish Independence, Ashya King, the NFL and dog ownership. Enjoy! Share! Feed back!

www.medicave.co.uk
@mdmedicave

If you want to download it to your computer, you can click this link directly.

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http://feeds.feedburner.com/PodcastMediCave

War On Drugs - Top Ten Films!

Have you seen End of Watch? My wife and I watched it this week and it made me (almost) cry. Not in the usual Hollywood way. And not in the Apollo 13 triumph over adversity way (the other film that always gets me). It’s a buddy movie about two cops in south-central LA who are doing their best to uphold the law and take down the bad guys. The crime in question is drug dealing and the violence that goes along with it.

It’s the way it’s shot as a realistic fly on the wall / found footage type thing (often a crap start to a film) that sucks you in and really makes you feel it at the end. No one wins. It made me think about the senseless loss of life on both sides of the law that have occurred in the War on Drugs.

So in true box-office style, here are my top-ten films that depict the tragedy of the War on Drugs.

10 - City of God

The birth of a Rio De Jeneiro cocaine empire and the violence that accompanies it.  Think of cocaine and cannabis and many will think of Central and South America. Be it the Columbian cartels, Mexican narco-terrorism or farmers surviving on growing 'Bolivian marching powder'. 

Several countries are making progressive strides though. One example is Uruguay, who are regulating production and sale of cannabis. This graphic from Drug Law Reform explains how it works. US states, such as Colorado are taking their own steps. As you can see, it's not designed to create a free-for-all, but to control who has access to cannabis. The aim is to take production and sale out of the hands of the criminals and place it within a regulatory framework.

9 - Scarface

The glamour of running a cocaine business in Miami! Until you end up hooked, friendless and full of bullet holes. This one is ridiculously over the top, but it shows where the money goes, to local gangsters, paying off officials and ultimately to huge and powerful cartels, leading to politcal instability and conflict in producing nations.

8 - Human traffic

The story of a night out involving alcohol, ecstasy, cannabis and, I think, cocaine.

This film is showing its age now. Ecstasy use is decreasing amongst young people, possibly being replaced by newer psychoactive substances - 'legal highs' and our drug laws are struggling to ban the substances quick enough. If they were all brought under the same regulation as alcohol, tobacco and other currently illegal drugs, then the onus would be on the manufacturer to prove contents and safety and scientists would stand a better chance of studying the substances to aid classification and control.

All drugs have adverse effects. I include alcohol and tobacco in that. There are, however, millions of people who take drugs and don’t end up as addicts or in hospital. They must enjoy themselves, or they wouldn’t take them. When people do come to harm, it is often a failure of education. When Leah Betts died in 1995 after taking ecstasy, there was a huge national campaign against the drug. It can be dangerous and there are deaths associated with it but in her case it was likely because she drank several litres of water in a short period of time (leading to low blood sodium levels and swelling of the brain) rather than the toxicity of the drug itself.

Educating users on how to avoid harm is a more pragmatic approach than hoping they won’t take it at all. Other fatalities have come because of mixing drugs together or taking drugs with dangerous impurities. If they were sold in a pharmacy, with warning labels and advice, this would be much less likely to occur.

Professor David Nutt was fired from the government’s Advisory Council on the Misuse of Drugs for suggesting a more coherent approach to drug classification, presumably based on actual harm to users and society rather than political hysteria and the thoughts of the Daily Mail. At some point he pointed out that ecstasy was less dangerous than horse riding as well as tobacco and alcohol though I think this was after his dismissal. Scientists do not say that drugs are safe, just that they should be classified according to harm. Many now think that legalizing and regulating (and of course taxing) is the best way to reduce this harm.

7 - Trainspotting

Fairly obvious but it does depict the devastating effects of heroin addiction and how hard it is to get off. It shows the strength of the addiction and the lengths to which people will go to get their fix. What it also shows is that the threat of criminal punishment does nothing to alter this. Whether it’s a crime or not, addicts need their drugs. Not all drugs are equal. There is no doubt that heroin is harmful. It wouldn't take long walking around my local city to find someone who has lost one or both legs due to the drug. People die from overdoses. People catch life threatening diseases from using dirty needles. Addiction fuels crime.

People need treatment and this takes time, effort and money. People also need to know that there’s a viable alternative life to the one that they are trapped in. Prohibition is a public health disaster. If you want people to take less heroin, locking them up is not the answer. They need support and compassion. Clean, unadulterated drugs or substitutes, counselling, needle exchange programmes, detoxification facilities, accommodation and the prospect of a job and a future.

6 - 25th Hour

The drug dealer’s going to prison. There’ll be another one to take his place. He made a shed-load of money but lost. The temptation will be there for the next one. I put this one in because Philip Seymour Hoffman is fantastic in it and now he’s dead. That’s very sad. The fact that his drug taking was illegal didn’t stop him wanting to take it. The fact that drug dealing is illegal doesn’t make them hard to buy. Prohibition failed and a great actor died.

5 - Requiem for a Dream

A tale of a dream of a quick buck from selling heroin turns to a tale of addiction and illness. The protagonist ends up in prison and there’s devastating physical consequences of his drug use. The American legal system is bonkers. Mandatory minimum sentences for drug offences destroy communities. Whole generations are in prison or dead. This chap is also denied proper medical care because he’s in jail. It’s no better for his mum though, who gets hooked on prescription diet pills.

If drugs were legalized and regulated, then more dangerous substances like heroin would only be available through pharmacies or other licensed medical establishments. There wouldn’t be a market for dirty or adulterated street drugs and this guy would have looked for another way to make a living and would have stayed out of jail or received proper treatment for his illness. The money saved in law enforcement and gained in taxing less dangerous substances, could be used for education and treatment to keep people off more harmful drugs.

4 - Breaking Bad

You’ve all seen it, people love it and yes, it's not a film. Thankfully crystal methamphetamine has not made a huge impact in the UK. Interestingly, whereas crack cocaine hit black neighbourhoods in the USA, meth has had a bigger impact on poor white areas. Again, it’s a cheap, highly addictive drug, with huge profits to be made and law enforcement cannot stop it. Educate, inform, treat, regulate.

Another point is that Walter started all his drug empire shenanigans because he was faced with huge medical bills after getting lung cancer. Under the NHS, his treatment would have been free. Remember that. 

3 - A Scanner Darkly

A messed up dystopian future (as most of my favourite books and films tend to involve) is the setting for this kind of animated live action film where a cop goes undercover to expose the source of a new drug called Substance D that has swept America. He is overpowered by the drug but does make some amazing discoveries along the way. This is the War on Drugs lost.

2 - The House I Live In

If you want to know more about what America's drug policies have done to its people, please watch this. This great docco interviews people on both sides of the failed War on Drugs. Police, officials, criminals, users and prisoners. Watch it, you’ll learn a lot. And look at their site.

1 - The Wire

Not a film, but the five series of this Baltimore-set show do more than anything else I’ve seen on TV or film to portray the futility of the War on Drugs. There’s good and bad on both sides. There’s murder after murder, death, relapse into addiction. There’s an overstretched police department who are struggling to keep up with the drug-gang related murders. There’s people born into families where ‘the game’ is all people have ever known, with no hope of a better life. Schools are underfunded and kids have no role models other than older gang members. There’s a couple of big winners and a whole heap of losers. The worst thing is that at the end of it all, nothing’s changed. This is a stunning examination of the War on Drugs, urban decay, education, law-enforcement, city politics and the media. It makes me laugh, shout at the TV, frustrated and sad and I love it.

More...

I could give all the arguments for and against legalizing and regulating drugs, but helpfully it’s been put in this great information leaflet by The Transform Drug Policy Foundation. It would be hard and there would be unintended consequences. It would require a lot of political will and international co-operation. A step-wise move towards the goal is the most likely. What we need to do now is have an honest debate about the pros and cons. Look at the evidence from other nations, make the conversation follow science and reason and not right-wing hysteria. People will take drugs, whatever the rules are. It's our duty to help reduce harm.

What is the Matrix?

The Matrix is everywhere. It is all around us.
Even now, in this very room.
You can see it when you turn on your television.
You can feel it when you go to work… when you go to church… when you pay your taxes.
It is the world that has been pulled over your eyes to blind you from the truth.

What truth?

That you are a slave, err, (insert your name here, unless it is Neo, then keep that one).

I watched it for about the twentieth time the other day. 1999, that film came out. My friends and I saw it at the cinema when we were 15. We hadn't seen a film like this before and were blown away by the special effects, the sounds, the slide down Nokia phone! Bullet time! And of course, the concept.

Now I don't actually think that we live inside a computer generated virtual reality. I'm also aware that I'm unlikely to be the first to compare the 'real' world to the Matrix. It still has a lot to say though.

As my walk through Ellesmere Port emphasised we are surrounded and bombarded by a world that is often out to hurt us, or at the very least, keep us quiet whilst bad stuff goes on elsewhere. Not all of it, not everyone, of course. The world is incredibly complex and everyone has their own set of incentives. The girl in the red dress isn't a computer program but has her own priorities and motivations.

But there is a system. Maybe multiple systems. Battling against each other. And it's hard to tell who is who. Companies have to make money. They have to make more money each year so people will buy their shares. They can grow their market, but if they have cornered the market then they have to make more money off each person. People within companies might care about your health, but most companies do not. They just need to sell you stuff. Maybe stuff you need, maybe not. Maybe they are selling booze, fags, takeaways, sugary drinks, time on the sunbeds or maybe healthcare itself. Either way, they care about profits. They care about your health if it is in line with their profits.

Now obviously companies employ people, but many don't care about their employees either.

On the other side should be the government, working for us, not for profit. National institutions such as the NHS are working for us, but bits are being snipped off and sold at an alarming rate. More and more contracts are going to private providers. This is often the more profitable end of an operation, leaving the NHS underfunded and having to cope with increasing disease with decreasing funding.

So let's break it down…
"You can see it when you turn on the television" –
'Television is the opiate of the masses'. The original quote was about religion by Karl Marx, not sure who coined the TV version. There is a lot of nonsense on TV. Watch it on Saturday night and you will gain little insight into the issues facing our world today. I asked someone if they were going to vote in the local elections. They said 'I don't know anything about politics, but how many Kardashians can you name?'

One, the one who married Kanye West.

TV is there to entertain us, but surely there's some room in there to educate us about what's going on. 15 million votes were cast for the final of series 7 of the X-factor according to the Wikipedia page (do not waste your time following that link). Yet only a third of eligible voters turned out for the local and European parliament elections this year. Some might say this was an argument for compulsory voting. I would say it's an argument for improved publicity and engagement, with options for online ballot casting. And compulsory voting.

Worse is the content between the programmes. If you watched TV for a whole day, how many adverts for unhealthy or high sugar foods, high interest short-term loans, gambling websites or booze would you see? How many would your children see? Advertising works, or they wouldn't advertise. I'm concerned when I see sexy young people 'vaping' on TV adverts. I'm sure e-cigarettes are better for you than tobacco, but that doesn't mean they should be promoted to young people as something cool to do.

"when you go to work" – Pretty broad this. How many people are trapped in low income or minimal wage jobs? Is there good job progression? Is there hope? Is childcare available and can you take advantage of training opportunities? Can you live an acceptable life on the minimum wage or are you still relying on benefits or debt? Employers have a responsibility to pay a living wage. If they won't, then the government has a responsibility to raise the minimum wage. Working full time should enable you to live.

"when you go to church" – Maybe you go, maybe you don't, but religious institutions still have an effect on your life. I went to Church of England schools and had to pray and sing with everyone else. I wasn't offered a choice until much later and it was never put to me that many people don't believe in Christianity and live perfectly fulfilling lives. 26 Bishops sit in the House of Lords and help decide our laws. Members of religious organisations are asked for their opinion on every topic under the sun and given a load of air-time.

Thought For The Day on Radio 4! What is that?! Programmes on Radio 4 should be either informative or entertaining. That is neither. Ditto The Archers.

"when you pay your taxes" – I've just read Thomas Piketty's Capital in the Twenty-First Century and it describes thoroughly and brilliantly how our financial and fiscal system funnels money from the poor to the rich and functions to widen the gap. We should have a progressive tax system that prevents the increasing inequality and divergence of wealth that we see in this country and others. Our taxation system benefits those who have money and power and wish to increase it. And I bet that you don't have access to an expensive accountant and aggressive tax-avoidance schemes.

There is enough money in this country to fund the NHS. We have good outcomes and provide excellent value to the taxpayer. If everyone paid their fair share and the NHS was given the funding it needed, we could do even better (and it would still be cheaper than most private systems).

"That you are a slave, Neo." – Not literally, I hope. But you probably aren't getting a fair portion of the fruits of your labour. I do not wish to promote wealth envy, just fairness (and I'm definitely not a communist!). The world is set up in a way that it is easy to make unhealthy choices and give your money to people who already have plenty. It's not designed to improve our health and well-being.

Later, the Matrix talks about the prophecy of 'The One' – "a man born inside who had the ability to change whatever he wanted, to remake the Matrix as he saw fit." In some way we all have this ability. (Imagine quiet music) It's our voice and our vote. If politicians are doing something you don't like, vote for someone else. Make sure that they bring in regulation that is there for you, not for the businesses that lobby them. (Music starts to build) We can choose the products that are sold to us by buying something different. We can make small changes in our lives that will make us healthier and take responsibility for our own well-being (louder). Write to your MPs, register to vote, write to the papers, rant on the internet! (music climaxes in a thundering crescendo!) We are all The One!

Boom, big finish. I frickin' love that film.