Tom Sharon Preoperative / intraoperative phases of surgery


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General Anesthesia: The Hidden Risks

This is the transition between the preoperative and intraoperative phases of surgery. I have heard doctors dismiss their patients' concerns by telling them, "You've nothing to worry about from the anesthesia. The risk is negligible -one in ten thousand, or less than one-tenth of 1 percent". This is promoting a false sense of security because the process of putting you under is loaded with danger. One in ten thousand deaths is one too many if you happen to be the "lucky winner". You should also know that most anesthesia-related deaths and incidences of brain damage occur because the anesthetist failed to pump sufficient oxygen into the lungs. This is not the result of some unexplained phenomenon or a full moon. It is the result of an unfortunate mix of sloppy work and arrogance.

Furthermore, the medical community in the United States may have been remiss in failing to explore a viable alternative. During the 1970s there was a great deal of interest in using acupuncture in place of general anesthesia for a number of operations. Though this trend seems to have died out, I wonder if the medical community has arbitrarily denied us the ability to choose an alternative to the risks of general anesthesia. In any case, you should explore the appropriateness of available alternatives, such as spinal or local anesthesia.
Back to our scenario: In a few minutes, the anesthetist is going to render Bob unconscious by injecting some drugs into his veins, putting him into a comatose state. Bob's entire body, including his respiratory muscles, will be paralyzed from an injection of a drug made from curare. This is always necessary to prevent a patient's sudden involuntary movement during surgery, which could cause a slip of the scalpel or another cutting tool.
Bob's life will depend on what happens in the next sixty seconds while the anesthetist secures his airway by sliding a tube into his throat. If the tube goes the wrong way, the respirator will pump the oxygen into Bob's stomach, and his face will turn blue and dark purple. The biggest problem with intubation is that the anesthetist has to do it blindly. He or she uses a laryngoscope to visualize the vocal cords. Then as the anesthetist moves the tube into the throat, it obstructs the view. Thus as soon as the tube is within striking distance, the anesthetist has to complete the forward thrust without visual guidance.
Furthermore, the anesthetist is at a disadvantage in trying to determine the correct tube size. There is no way to measure for the correct diameter. If it is too small, it will leak air and the lungs will receive insufficient oxygen. If it is too large, there is a serious danger of rupturing the trachea and causing a bizarre condition called subcutaneous emphysema. The entire upper body puffs up like a rising souffle because the negative pressure within the chest literally sucks air into the fatty tissue beneath the skin. This is somewhat rare, but it is well documented and can happen to anyone. The following is how a doctor described such a case that I once reviewed for the patient's attorney: "The endotracheal tube passed through the vocal cords with some difficulty and within ten minutes the patient exploded with tense subcutaneous emphysema throughout his upper body. By tense, I mean beyond anything that I could have imagined. The head, neck, chest, and abdomen were massively edematous to the point that I could not palpate his sternum or his ribs and I was unable to palpate the anterior neck for an accurate tracheotomy." This patient died because once the integrity of the windpipe was violated, it was impossible to establish an airway.
However, this kind of reaction is not necessarily fatal. In other cases, the airway had been established, the air in the tissue dissipated, and the puffiness resolved spontaneously (went away by itself). I witnessed such a case about twenty years ago in the emergency room of Lincoln Hospital in the South Bronx (New York City). An elderly man was brought in by ambulance because he was going into respiratory failure from severe asthma. The intern on duty tried to put a breathing tube that was too large into the man's throat. The trachea ruptured, and I saw the same phenomenon just described. I ran out into the hallway to get help and found one of the senior surgery residents walking along with a cup of coffee. I snatched the cup from his hand and pulled him into the treatment room to show him the patient. The surgeon immediately performed an emergency tracheotomy with the tools that I handed him, and he inserted a breathing tube through it. I was then able to attach it to a respirator. The man survived.
A few days later I visited him in his hospital room. The tracheotomy was closed, the swelling was gone, and he was talking normally. He ultimately went home and returned to his regular activities.

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