Can I opted out of General Anaesthetic?

You're quite clearly upset about something to do with general anaesthetics. As to what exactly, I'm not sure. I think you should take a few deep breaths.

At no point did anyone say it is perfectly safe. Of course it carries risks. So does crossing the road, flicking a light switch or chopping up vegetables with a knife.

For a start, we can't do it on each other due to the drugs involved. One of them is a controlled drug. We can't just give controlled drugs willy nilly.

Secondly, it does carry risk. As does any medical procedure. You take paracetamol for aches and pains despite the fact that it can cause liver damage. You cross the road at a zebra crossing even though a car might not stop. But if you had no real need to cross the road, you wouldn't bother, the same applies for a general anaesthetic.

Thirdly, there's no need to try it out on each other. That provides no teaching. A one on one supervised session with real patients is much more effective for a start, and is appropriate because the patient is undergoing a procedure which requires a GA. I would ask you, michael, what your supposed alternative would be for an aortic valve replacement, a fundoplication procedure, or a laryngeal tumour removal?

You are more than welcome to decline a GA, but if there is no alternative to being able to do your procedure, then you can't have it done, pure and simple.

In regards to STD above - the surgeon has only a minor role in the decision making into how your operation's anaesthetic is done. It is the anaesthetist's decision. The surgeon can suggest some factors which may sway the decision of the anaesthetist, but the final decision lies with the anaesthetist alone.

There's a difference between "bullying" a patient into an option, and simply stating that the only way an operation can be done with minimal risk is via a general anaesthetic. There are situations when a regional anaesthetic is the safer option, at which point that is the direction we try to go. For example, last weekend I spent over an hour with a patient advising them to have a spinal as opposed to a GA, as in that particular circumstance, it was much safer. With the information and discussion, they decided to go down that route, and were much happier post-operation for it.

And there comes a point when Dr Google and The University of Wikipedia do not stand up to years upon years of education in a specialist field. Anaesthesia is something that is fairly poorly understood, even amongst the medical field in general. That's not to say a patient doesn't know about what they are undergoing, but it's highly unusual, and a quick google search doesn't even begin to cover the basics of anaesthesia, especially if you are biased towards looking for anything and everything negative. No human is infallible, doctors included, but we are trained to provide the safest route amongst many options - if we are of the opinion that your operation can only be done one way, although we cannot and will not "force" you to have it done that way, likewise, a patient can never "force" a doctor to provide care which they believe is unsafe, or not in the best interests of the patient.

There's too much hysteria going on here, so I don't think I'll contribute any further, unless there is someone with a genuinely serious concern, as opposed to the frothing at the mouth that this tread is heading dangerously towards.

So just to be clear, tell us which fairytale book you are reading.  Then it could be helpful if you imagined you fell ill with peritonitis - are you going to go down with the peritonitis or shut your eyes when the anaesthetist arrives and make the best of it. I am assuming that you would ignore the prior appendicitis because that could not be serious enough to warrant any anaesthetic.

"Combined spinal epidural anesthesia for laparoscopic appendectomy in adults: A case series" at:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3299110/

and:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016173/

 

Oh dammit, I'll bite.

I'm sorry, but your reply clearly demonstrates the point that looking up results in Google does not equate to specialised medical education. These papers are cherry picked examples - their major flaw: these are virtually all elective patients, and even in those emergency cases, a clear caveat is added in the second, larger paper: "The prime indication for using regional anesthesia in therapeutic laparoscopy is still limited to patients unfit for GA".

If we take Jaguar's example - peritonitis as a result of a ruptured appendix, you would of course need an emergency procedure, at minimum, a laparoscopic appendicectomy with abdominal washout, or if peritonitis was set in enough, a fully blown laparotomy. At this stage, you would at least be in the early stages of sepsis.

A regional approach would may be insufficient for several reasons:

1) A septic patient would be at much higher risk of developing either a mengingitis from transferrance of bacteria into the subarachnoid space from a spinal, or of an epidural abscess for the same reason into the epidural space, significantly increasing the likelihood of developing an epidural abscess, which can result in paralysis from anything innervated from antying below the lesion.

2) To adequately cover a peritoneal washout, the block level for a regional technique would need to be T4. At this level, you are highly likely to develop hypotension, which in addition to the septic trigger from your peritonitis, would leave you dangerously haemodynamically unstable, require profuse amounts of vasopressor support to maintain blood pressure. In addition, you increase the likelyhood of blocking the cardio acceleration fibres, leading to a dangerous bradycardia, which in the presence of a severe hypotension, could be nigh on fatal.  The papers you quote are for fit, ASA I-II grade patients undergoing an elective procedure in the first paper, of which 25% required some form of haemodynamic support. In the second paper, 18.21% of people required haemodynamic support, despite a significant proportion of the procedures not requiring a significantly high block. A septic patient may already be requiring some form of inotropic support so to do something (a regional appreoach) which, in an ill patient, will massively increase the need for inotropy, it is a massive, unnecessary and no doubt in some cases, a deadly risk.

3) It could be extremely uncomfortable, as the spinal/epidural would not be able to cover the C3, 4 and 5 nerve roots that supply the central part of the diaphragm, which would result in severe discomfort/pain when washing out that area, or swabbing it to clear pus. To cover that area completely would obviously compromise breathing completely.

4) A combined spinal epidural approach (CSE) cannot be relied upon for extended procedures. Approximately 1 in 10 epidurals have some degree of inadequate block, and the epidural cannot be tested after insertion due to the spinal blockade being present. In the middle of a procedure, should you require the epidural as the sub-arachnoid block is wearing off, and you find it is not working, it would necessitate a switch to a general anaesthetic. Although the conversion rate is fairly low, if you were absolutely refusing any GA at any time, then that alone would preclude you having even the regional.

5) I'm going to assume you aren't on any blood thinning medications, in particular, clopidogrel nor dabigatran, neither of which are reversible. This is a significant, if not absolute contraindication and would prevent a regional anaesthetic technique from taking place in an emergency situation.

There is a reason why dangerously unstable patients in intensive care are sedated and ventilated (basically, an extended general anaesthetic), because sometimes, it is clinically necessary.

Although I would agree that a CSE is an option in laparoscopic procedures and in some cases, will be the preferred option, in an emergency situation, it is a poor option in many cases (with some notable exceptions), and one that carries far too many unnecessary risks. The safest option would, in the above example for a normally fit individual, be a rapid sequence induction general anaesthetic, with, if locally available, a desflurane volatile anaesthetic with a remifentanil TCI to significantly reduce the amount of anaesthetic agent needed.

A few "cherry picked" studies to refer to:

http://www.unboundmedicine.com/medline/citation/19596539/%5BOptimization_of_anesthesia_for_emergency_abdominal_surgery_in_the_elderly%5D_

http://www.ncbi.nlm.nih.gov/pubmed/14982571

http://www.sciencedirect.com/science/article/pii/S0952818099000616

And no-one has yet to address an alternative for cardio-thoracic, neuro, maxillo-facial or most ENT procedures.

Please don't go off in a huff - you're educating the uneducated. I said near the beginning of this thread that probably would be to discuss concerns about GA with their GP or ask at the hospital for a consultation with an anaethatist - even to the extent of seeing whether it'd be possible to witness the care that goes on. Do you think these are sensible suggestions and can you support them and maybe give guidance on ways forward to ease the concerns ?

Mike.

It's a fair question.

My advice would be to consult the anaesthetist in the hospital. This is, at least for routine elective day procedures, done on the day of the operation. High risk patients will see an anaesthetist in clinic beforehand. There is no harm in asking for a referral to an anaesthetist prior to procedure to discuss any concerns.

Although a GP will know the very basic parts about an anaesthetic, they probably would not be able to answer any of the questions of the nature of this thread.

As I alluded to earlier, anaesthesia has been compared to flying concorde. You would not be able, as a member of the public, to be able to witness what the pilots are doing first hand in the cockpit as it would be a dangerous distraction for the safety of the aircraft. Likewise with anaesthesia, the most dangerous parts of your anaesthetic are the induction and the waking of the patient, and it would be unsafe to have an added distraction in the room of someone who is observing for observation's sake. This is even before the aspect of patient confidentiality.

The anaesthetic room is a strictly no entry room to anyone other than anaesthetic staff while induction is happening, including professors and consultants of surgery. In our hospital, continual flouting of this rule can result in disciplinary procedure.

Hope that answers your question

We don't use "gas". It's a vapour. A vapour that causes a degree of haemodynamic instability and loss of airway reflexes. Without management, it is dangerous. So you either have a full anaesthetic or none at all.

Would you ask the same to a cardiac surgeon - "Do you guys just pick someone out of the class to try transplanting their heart? How can you say it's safe otherwise?"

And no, I wouldn't ride roughshod over your objections. If you were of sound mind and able to make the decision, we would say fine. This may of course, lead to your death, at your own choice.

I need to add, if you were seriously injured, we wouldn't be able to admit you to intensive care either as we wouldn't be able to sedate and ventilate you (an extended general anaesthetic).

Instead of scare mongering Micheal I would read the whole article and you will see that he had cardiack problems among other co-morbities I myself have that many that any major surgery is ruled out except in an emergency I would imagine this gentleman would have attended a pre-op clinic prior to any surgery although I could not understand why he went in for such massive surgery such as an artificial knee joint.

I cannot understand why the doctors continued with the operation when the poor man started to complain about uncomfortable chest pains. They seemed to sensibly use a regional anaesthetic and then ignore its benefits when they ignored the patient's severe complaints.

There comes

 

I was trying to add that there comes a point where the CPS should be investigating and considering a prosecution. The NHS trust seems to be admitting a "mistake" and therefore civil and financial liability. Perhaps they should not be able to get away with just that. Occasionally, someone needs to answer to a criminally based charge. From the facts available, someone (perhaps the main surgeon) seems to have made an appalling mistake which common sense could have avoided. He may be guilty of a grossly negligent act which resulted in the manslaughter of this poor patient.

None of us are qualified surgeons let alone surgeons with a lot of experience. We are not in any position to understand the how and why and probably would not be able to even if we had been in the operating theatre. This is not a zero sum game.

Furthermore the press report like any other press report is made by someone who cannot know and understand the technicalities or even the human thoughts of a surgeon faced with decisions about life threatening conditions. There is no time to stop and stare, to sit down and have a cup of tea and discussion with other medics.

The media is all about headlines that will attract our attention; actual facts may be difficult to report without undermining those headlines. We simply do not know all the facts let alone the thoughts going through the heads of surgeons.

It is quite ridiculous for us to regard surgeons (and even most doctors) as being able to control every possibility as if they were, say, accountants or lawyers or farmers. Every single person is a different medical person and will present some difference(s) against all others.

Surgeons obviously cannot control every medical possibility or last minute problem that arises. For that matter, neither can accountants (eg. client goes bust), lawyers (witness contradicts himself in the box) or farmers (eg. crop blight or mad cow disease). However, what can be expected of all professionals, is that they take all objectively take reasonable, justifiable steps re. their actions. Ignoring a patient's whimpers in the operating theatre about chest pain does not seem, prima facie, a reasonable thing to do. Perhaps the surgeon had a good reason to do so, but, call me unqualified or not, it does seem like a rather odd thing to do. The patient subsequently died. We should not accept a culture where doctors and surgeons are immune from liability. The Courts in this country are still quite loathe to challenge doctors for any but the most serious mistakes and our levels of financial damages are paltry compared to, say, the US courts. It's not enough to say that the NHS will learn from this event. Serious investigations are called for.

 

Damages. Serious investigations. Courts. Lawyers. And reporters. You obviously see the ridiculousness of expecting other professions to make the right decisions. That is surely the human condition. But all this mention of comparing us to the US and what you think we should do is still without any personal knowledge of events to back up your claim not to understand the doctors, as if you should be able to be in their minds. Why? Are you a frustrated doctor? Why should we be anything like the legally obsessed Americans who expect money compensions as a right for anything and everything.

We do not live in a perfect world and it is impossible to imagine any such thing. There are many wrongs happening every day all around us. Instead of getting overheated about any one thing our better approach ought to be to work for achieving better lives for all. I might find it easier to agree with you if you said you cannot understand what the politician has done if only because there is a bit of the politician in all of us which then enables us to think along the same lines.

I was not comparing us directly to that US. I was just noting the disparity in financial damages. In fact financial damages are my least concern because I don't really think that money compensates for someone's lost life. I am much more concerned about the criminal lack of accountability within the medical  profession - someone dies and no real further investigations are carried out. It is presumed that nothing illegal or untoward happened. I obviously don't expect the medical profession to "snitch" on its own, which is why I suggest that, given the human importance of this subject, we need objective 3rd party outsiders to do this.

I am certainly no frustrated doctor. Both my father and grandfather were involved in animal medicine and my mother was a midwive before she married. I am a practising barrister who fled the smelly farmyard and suffocating attitude that the NHS nanny knew best, 

Again the computer flickered and posted before it was meant to. I would finally add that I had first hand experience of the condescending attitude of certain medical professionals. I personally prefer representing the underdog.

I think that condescending attitude is fast disappearing and I am with you when it comes to helping the underdog. So what about the Coroner? And even the police? The awful publicity given to the many cases where further investigation is necessary has had an impact. But we'll never have a perfect system.