This is a list of my articles, book reviews, news stories etc. Some have been published in newspapers, magazines, anthologies etc or online. - C. A. Broadribb.
Many writers have shared their thoughts with the public:
Anaesthesia for Operations
Copyright © C. A. Broadribb 2018Index:
Introduction.
Types of Anaesthetic.
Anaesthetists.
Choice of Anaesthetic.
Informed Consent.
Risks.
Hospital Procedures.
Emergencies.
After an Operation.
Medical Records.
Detailed Information - Local Anaesthetic.
Detailed Information - Regional Anaesthetic (other than a spinal block or epidural).
Detailed Information - Spinal Block.
Detailed Information - Epidural.
Detailed Information - Combined Spinal Epidural.
Detailed Information - General Anaesthetic.
Detailed Information - Sedatives and Sedation.
Making Complaints.
Websites for Additional Research.
My Experiences:
Experience 1: The dramatic effects of a sedative.
Experience 2: Cancelling an operation.
Experience 3: Choice of anaesthetic.
Experience 4: Misinformed consent.
Introduction:
Anaesthesia prevents you from experiencing pain while having an operation, and often also prevents you from being aware of what's going on or from remembering things afterwards. While you're under anaesthetic, staff members monitor and maintain your essential bodily functions such as breathing, temperature and blood pressure.
It's difficult to obtain information about anaesthesia online because most websites either have a simplistic description of a few sentences or a lot of dense technical information from research papers that most people won’t understand. There are also some differences in the terminology used by different sites.
This is a summary of information that I’ve obtained from various sources (websites, books, anaesthetists, and my own experience). It’s about anaesthesia for adults, specifically, and focuses on the situation in Australia.
This is general information only, not medical advice, so don't make any decisions based on it. Consult an anaesthetist or other medical practitioner for medical advice.
Types of Anaesthetic:
There are three categories of anaesthetic used to prevent pain during an operation.
- Local anaesthetic: a drug is used to numb a small area of your body.
- Regional anaesthetic: local anaesthetic is used to numb a large area of your body.
It can also called a ‘block’ or 'regional block' or similar.
Spinal blocks and epidurals are special types of regional anaesthetic. - General anaesthetic: a combination of drugs is used to put you into a deep level of unconsciousness.
Sometimes it's called ‘light general anaesthetic’.
It's possible to have more than one type of anaesthetic at the same time. For example, you might have local or regional anaesthetic with general anaesthetic.
Sometimes, in addition to anaesthetic, you will have a sedative drug to become sedated: relaxed, drowsy or in a light level of unconsciousness. It also causes memory loss.
Both laypeople and medical staff use the word ‘sleep’ as a euphemism or simplification when referring to the unconsciousness of general anaesthetic or sedation. However, both are unnatural, deeper levels of unconsciousness than sleep, and you can't 'wake up' (regain consciousness) until the anaesthetist stops giving you drugs and their effects wear off.
Anaesthetists use standard terminology when talking to other medical staff members or filling out medical records but when talking to patients sometimes make up their own terminology or use ambiguous or misleading language.
Anaesthetists:
Anaesthetists study a medical degree then complete additional study and training in anaesthesia over a number of years. They use powerful, dangerous drugs and medical equipment and - with the help of other medical staff members - literally keep you alive during an operation.
They need certain qualities to do the work. All of them are highly intelligent. They also need to be mentally tough to handle the stress of the job. They’re expected to develop some sort of rapport with you so they often have (or affect) a friendly, cheerful or caring manner. Like other medical staff members, they often deliberately act in a casual and relaxed way around you, presumably to avoid causing you additional stress in what is already a stressful situation.
Sometimes, anaesthetists make mistakes, fail to explain things properly or mislead or lie to a patient, regardless of how highly qualified or experienced they are or how nice they appear to be. Sometimes they mislead or lie to other medical staff members or medical authorities.
Like all medical practitioners in Australia, they’re listed in the Australian Health Practitioner Regulation Agency (AHPRA) database, accessible through the AHPRA website. They’re legally expected to update their employment details within 30 days of any changes, but don’t always do so.
Choice of Anaesthetic:
Whether it’s possible to have a choice of anaesthetic for an operation or not depends on the type of surgery you’re having, the hospital’s policy, and the anaesthetist’s and surgeon’s skills and attitudes.
Some types of operations can only be performed under general anaesthetic but others can be performed under local or regional anaesthetic instead. Unfortunately, even then there’s a small possibility that it won’t be completely effective and that general anaesthetic will be the only other option for the surgery to proceed.
Some hospitals have a policy of offering you a choice of anaesthetic whenever possible, some use general anaesthetic for all surgery, and some don’t have a set policy either way. Even when there is a policy, medical staff members have their own opinions and don't always promote or follow the policy e.g. a medical practitioner might try to persuade you to have general anaesthetic even when local or regional anaesthetic is possible.
Not all anaesthetists regularly use all of the different types of anaesthetic or are highly skilled in all of them. They may prefer to use a particular type. Some anaesthetists only work on certain types of operations.
Some anaesthetists are happy to let you help choose the type of anaesthetic where possible, but others, such as older ones, have the attitude that they should make all of the decisions and that you should have no say in it. This is unfortunate because older, more experienced anaesthetists are likely to be more proficient in the different types and be able to use them for a wider range of operations e.g. they might be able to use local or regional anaesthetic for surgeries that less experienced anaesthetists wouldn't use it for.
Sometimes, in a busy hospital, anaesthetists won't want to spend time explaining options of local or regional anaesthetic to patients who don't know much about anaesthesia or have poor English language skills. The anaesthetists may find it easier to use general anaesthetic.
Surgeons don't make the decision about what type of anaesthetic you have, but they can discuss it with the anaesthetist and yourself, and they can refuse to perform the surgery under particular types of anaesthetic. Some surgeons prefer to operate on unconscious patients under general anaesthetic, and some are too rough to operate on conscious patients. Anaesthetists and surgeons often develop close working relationships and understand each other’s skills and attitudes.
Although the Australian Charter of Healthcare Rights includes a communication principle of ‘I have a right to be informed about services, treatment, options and costs in a clear and open way’, and a participation principle of ‘I have a right to be included in decisions and choices about my care’, hospitals don’t seem to regard it as applying to anaesthesia, and set their own policies instead. The charter doesn’t mention anaesthetic specifically.
Informed Consent:
Informed consent is an important principle of medical care. The anaesthetist or other medical staff member should explain what type of anaesthetic will be used, give you honest and accurate information about it and answer your questions about it. You should be able to decide whether to proceed with it or not, without being pressured or coerced into it. Medical staff members should tell you about likely significant risks, however, they aren't required to tell you about all of the risks.
You usually have the legal right to refuse medical treatment, including being able to refuse to have particular types of anaesthetic or to cancel the operation altogether. You can do that even if you’ve already signed a consent form and even if you’re in the anaesthetic room or operating theatre and the anaesthetist is about to give you drugs. Staff members should respect your rights. However, sometimes they can be disdainful or get angry about it.
The Australian and New Zealand College of Anaesthetists has guidelines on informed consent, however, anaesthetists don’t always follow them. An anaesthetist is more likely to explain things and be honest at an anaesthetic consultation before the operation date rather than during a brief discussion just before the operation starts. You might have been rushed in with a serious medical problem or you might have had local or regional anaesthetic only to find it ineffective, or you might have successfully had local or regional anaesthetic but become extremely nervous when the operation was about to start. In those situations, the anaesthetist might not explain options very well or might give inaccurate or misleading information or gloss over the risks of anaesthetic in order to persuade you to go ahead with it. Other staff members present might not speak up about it. Staff members who enter the operating theatre later on might assume that the situation was informed consent.
If you were given a sedative to help you relax beforehand, it can cause additional issues. It can affect your decision-making ability, making you more likely to agree to an anaesthetic option that you might not otherwise agree to. It also causes partial or total memory loss, so that after the operation, you might not remember exactly what the situation was, what the anaesthetist said or what you agreed to.
There are situations where it’s acceptable for an anaesthetist to give anaesthetic without informed consent. For example, if you're unconscious when brought in to the hospital, or too badly injured to understand what's going on, or if a medical emergency occurs during an operation and the anaesthetist needs to act very quickly to save your life. Some patients aren't able to give informed consent for other reasons such as serious intellectual impairments or mental illnesses.
If you’re capable of giving informed consent then it’s a serious medical, legal and ethical issue for an anaesthetist to administer anaesthetic without it. If you agree to anaesthetic based on misleading or inaccurate information, it's 'misinformed consent' and can be regarded as medical negligence. If you're given anaesthetic without any consent at all, it's assault.
Risks:
Australia is one of the safest countries in the world to have anaesthetic. Anaesthesia is also much safer than it was decades ago because of medical advances. Unfortunately, local, regional and general anaesthetic still carry a small risk of side effects, injury and even death. However, anaesthesia is usually less risky than the surgery itself.
The chance of having problems because of anaesthetic varies depending on your health status. You’re at less risk if you’re young and healthy and at higher risk if you’re elderly, ill, seriously injured or have a chronic medical condition. Other factors that increase the risk are being overweight, being unfit, smoking, drinking alcohol or using recreational drugs. Having anaesthesia for a long period of time (e.g. for a major operation that lasts many hours) increases the risk of something going wrong.
It’s also possible for an anaesthetist or other staff member to make a mistake (such as giving you the wrong dose of a drug, or inserting a breathing tube incorrectly) or for medical equipment such as an anaesthetic machine to malfunction or fail. Staff members are trained in handling problems, including emergencies, so they should be able to take steps to help you if something goes wrong.
According to the Australian Society of Anaesthetists website, a large study showed that only 10% of patients had problems from anaesthetic, and that the most common problems were relatively minor, such as nausea, vomiting or a sore throat.
Another issue is that the anaesthetic might not be completely effective. There's a small possibility that local or regional anaesthetic won’t completely numb the area to be operated on or will wear off partway through the operation. There’s a slight risk that general anaesthetic won’t keep you completely unconscious throughout the operation, especially if a light dose is used. The anaesthetist might be able to give you more anaesthetic, a different type of anaesthetic or additional drugs.
Although websites about anaesthesia claim that an anaesthetist or other medical practitioner will discuss relevant information with you before the operation, including telling you how likely the anaesthetic is to be effective and warning you of likely risks, this doesn’t always happen, especially in busy hospitals. Staff members might not say anything about risks, only briefly mention a few of them or only mention afterwards that there had been a particular risk. Even if you bring up something that you’re concerned about, the anaesthetist or other staff member might not acknowledge or discuss it.
Hospital Procedures:
Hospital procedures will be similar regardless of whether you have elective surgery (planned in advance) or arrive at the Emergency Department badly ill or injured. However, for elective surgery, hospital staff will make a number of appointments for you to come in to the hospital for consultations or tests days, weeks or even months before the planned surgery date. That leaves you time to do your own research and think things over. If you arrive at the Emergency Department, everything will happen quickly and you'll probably have the operation on the same day that you were admitted, or the next day or within a few days.
Procedures will be similar in private and public hospitals. (Note that most private hospitals don't have Emergency Departments and handle only elective surgery.) At a private hospital, you're much more likely to be able to talk to the surgeon and anaesthetist who will treat you during the operation, whereas at a public hospital you will probably talk to someone different - whoever happens to be available at the time. Even for elective surgery planned months in advance you probably won't meet the surgeon or anaesthetist who will treat you until just before the operation starts.
At a surgical consultation, a medical practitioner will give you basic information about the proposed operation and ask you to sign a consent form for it. He or she might briefly discuss anaesthesia. Hospitals in Australia don’t usually have separate anaesthetic consent forms so the surgical consent form is taken to include consent to anaesthesia even if it doesn't have a section specifically for it and even if you're asked to sign it before you have a chance to talk to an anaesthetist.
You might be able to have a separate consultation with an anaesthetist. Then you can ask what types of anaesthetic are possible and discuss the risks and benefits. However, there won't be any written record of what types you're willing to have and what types you would like to refuse (if any). Also, at a public hospital, the anaesthetist you talk to might have different skills and attitudes from the one assigned for the operation.
You'll need to have various tests before an operation to evaluate your health and fitness level. Staff members might take blood samples, ask you to do breathing tests, take X-rays, use an ECG to measure your heart function etc. They might check your mouth to determine how easy it would be for an anaesthetist to insert a breathing tube during general anaesthetic. They might ask you about medical problems, medications or supplements that you’re taking and previous operations and anaesthetic that you’ve had.
You need to avoid eating or drinking anything for many hours before an operation, if possible, because food and drink could interfere with anaesthetic or cause other problems e.g. you could vomit and choke. Of course, during an emergency situation, you won't have time to fast so staff members will have to take extra steps to keep you safe.
When it’s time for the surgery, staff members will ask you to change into a hospital gown and lie on a bed, then wheel you to the anaesthetic room where the anaesthetist assigned for the operation will talk to you. The discussion might be brief and unsatisfactory if he or she is under time pressure. Although there will be many staff members present during the operation, they won’t all be present for the discussion about the anaesthetic. There might be only one nurse in the room at the time, who won’t necessarily speak up if the anaesthetist says something inaccurate or misleading.
The anaesthetist will either administer anaesthetic in the anaesthetic room or move you into the operating theatre to do it. It can be daunting to have it done in the operating theatre because of all of the unfamiliar medical equipment around you.
Staff members will perform a variety of tasks to prepare you for surgery. They will confirm with you what type of operation you’re going to have and that you signed the consent form for it. However, they might not confirm what type of anaesthetic you’ve agreed to. Other preparatory steps can include inserting a catheter into the back of your hand to give you intravenous (IV) fluids; attaching equipment to monitor your vital signs such as heart rate, blood pressure and blood oxygen level; asking you to breathe air through a face mask; shaving hair off the area to be operated on; wiping the area with antiseptic fluid; putting a warming blanket over you; placing gel heel pads on your ankles etc. If you’re going to be conscious during the operation then a screen or blankets will be used to block your view of the surgery. Sometimes medical staff will want to insert a urinary catheter for a spinal block, epidural or general anaesthetic. Some hospitals have a policy of always using one for general anaesthetic - the staff might put it in after you’re unconscious, without your knowledge or agreement.
Numerous staff members will be present during the operation, e.g. an assistant anaesthetist, surgeon and assistant surgeon and nurses. Their names will be recorded on your medical record. If you’re in a teaching hospital, other people may come in to watch and learn but won’t be noted down.
While the operation is in progress an anaesthetic machine is used to monitor your vital signs and give you drugs though the IV line. If you have general anaesthetic, it can also give you a gas through a tube in your throat. It includes a ventilator which breathes for you if you can’t breathe on your own under general anaesthetic (which, often, you can’t).
After the operation is over, the anaesthetist and other staff members will usually move you to the recovery room - also called a PACU (Post Anaesthetic Care Unit) - where nurses will look after you while the anaesthetic wears off. You might need to stay there for a number of hours. Then you might be able to go home or might be moved to a ward for further rest, monitoring and\or treatment. If something went wrong during the operation or if it took a long time, you might be taken to the Intensive Care Unit (ICU) instead.
Emergencies:
If you need immediate medical treatment because of a life-threatening emergency then staff members will follow different procedures from usual. They'll usually take whatever action is necessary to save your life and try to keep you as safe as possible while doing so. It might not be possible for them to explain what type of surgery or anaesthetic you will have or to ask for your consent.
The only time they won't try to help you is if you had previously signed a ‘Do Not Resuscitate’ or ‘Not For Resuscitation’ or similar order to refuse particular types of life-saving treatment such as CPR. Terminally ill patients sometimes do that, because treatment wouldn’t help them much – at best, it would return them to the same severely ill state that they were in before.
After an Operation:
You’ll physically feel very bad after an operation, regardless of what condition you were in before you went through it. You can be hot, tired, ill, in a lot of pain, have difficulty concentrating etc. Hospital staff might give you painkillers and other medication to take at home but they only help up to a point, and they can have side effects such as making you drowsy. Nobody's likely to warn you in advance of how badly you'll feel. You’ll gradually feel better over the following days and weeks.
A website reported that people also often feel emotionally low while recovering from an operation, but suggested that this could be because of having time for reflection while taking a break from their usual activities than being a side effect of the operation or anaesthetic.
Your body will gradually heal itself as much as it can. It takes at least six weeks to recover from an operation, and sometimes much longer. You might be asked to have a number of check-ups or have treatment such as physiotherapy. If you suffered nerve damage from an injury, the operation or the anaesthetic then it might completely or partially heal over a number of months or might be permanent.
Medical Records:
The hospital owns your medical records, however, you usually have a legal right to look at them. That applies to both public and private hospitals. You can make an appointment to go in to see them or order a copy of them (you might have to pay a small fee). Sometimes, there are legal reasons for a hospital to refuse to allow you to see them.
The records can include forms filled out before the operation, test results, nurses’ notes, anaesthetist’s and surgeon’s notes and anaesthetic machine printouts. The latter will show various readings such as heart rate (HR), blood pressure monitoring (Art NIBP for Arterial Non-Invasive Blood Pressure, and CV for Central Venous pressure), blood oxygen levels (SPO2 using a device called a Pleth - Plethysmograph), temperature (T1, T2), blood supply problems (ST for Systemic Event), oxygen given (O2%), nitrous oxide anaesthetic gas given (N2O%), other anaesthetic gas given (e.g. Sev% for Sevoflurane) and carbon dioxide exhaled (CO2).
It's difficult to understand medical records. They can use unfamiliar abbreviations and terminology. Anaesthetic machine graphs can be hard to decipher. Staff members’ handwriting can difficult to read. Patients often expect that all conversations, procedures and events will be documented, but this isn’t always the case, particularly when there's only limited space for a staff member to write notes on a form.
Sometimes medical records have inaccuracies. Staff members occasionally misunderstand things e.g. a nurse may be mistaken about what type of anaesthetic was used. Occasionally, staff members deliberately falsify medical records. This is professional misconduct and is a serious issue.
Detailed Information - Local Anaesthetic:
Local anaesthetic uses a drug or drugs to numb a small area of your body. It can also be called ‘local infiltration’. Usually, an aneasthetist administers it but sometimes another medical practitioner does, such as a surgeon.
It's usually used for minor operations such as cataract eye surgery, a biopsy, removing a mole or wart, repairing a toenail or operating on a finger. (Dentists also use it for dental procedures.) Sometimes it’s used for brain surgery, because only the outer areas need to be numbed – there aren't any pain receptors inside a person's brain.
Local anaesthetic isn’t suitable for many types of surgery because it doesn't always reach the appropriate nerves (some aren’t easy to reach) or affect the pain receptors in internal organs. In some cases, the dose required for the operation would be too high and would be risky for you or cause problems for the surgeon e.g. by distorting tissues.
If you have local anaesthetic then often the doctor will give you a light dose of a sedative first to help you relax, because the anaesthetic is more likely to be effective if you aren’t anxious. Note that the sedative will also cause some memory loss afterwards.
Local anaesthetic is applied using an injection, drops, spray, gel or ointment. It isn't intended to go into your bloodstream. You might feel some tingling or pain. It takes effect within minutes, making the area go numb. You'll still be able to feel pressure and movement because they're registered by different nerves than the ones that register pain. There are rare occasions when the anaesthetic isn't effective. In that case, an anaesthetist might be able to give you another dose or give you painkillers, or you might need to have regional or general anaesthetic or you could cancel the operation. Some people are resistant to local anaesthetic because of genetic factors.
If local anaesthetic is effective then you can remain conscious during the operation. However, it can be frightening to suddenly be surrounded by bright lights and unfamiliar medical equipment and to know that the surgeon is about to cut into you. You could have a sedative, or an additional dose of it, to make you relaxed or drowsy (and unable to remember much afterwards). Or you could have sedation or general anaesthetic to become unconscious and unaware of everything that's happening.
Local anaesthetic usually lasts for a number of hours - even up to 24 hours. After the operation is over you have to take care not to injure that part of your body, as you won’t be able to feel it. After the anaesthetic wears off, you might need more painkillers.
Local anaesthetic is safer than regional or general anaesthetic. However, as with all types of anaesthetic, it still carries a small risk of side effects, injury and even death. The list of possible problems can sound alarming, however, you might not experience any of them, or might experience only one or two minor problems. You might prefer to take the small risk of having local anaesthetic rather than leave the medical problem untreated.
Uncommon problems: bruising, bleeding or soreness.
Rare problems: a headache, blurred vision, dizziness, vomiting, muscle twitching, damage to your blood vessels or tissues or nerves. Nerve damage can cause numbness, weakness or pain in the part of your body that the nerve goes to. It’s usually temporary, lasting between a few days and a number of months, but occasionally it's permanent.
Very rare problems: an infection, an allergic reaction, falling unconscious if a large amount of the drug unintentionally gets absorbed into your bloodstream, lung problems, heart problems or a heart attack.
Be wary of private medical clinics and cosmetic clinics that perform procedures in-house under local anaesthetic with a sedative or sedation. They aren’t sufficiently regulated or monitored by the authorities. Also, doctors who perform cosmetic surgery aren’t legally required to have the same qualifications and training as normal surgeons - they can even just be GPs. You could be at increased risk of having problems during or after the operation and might not be happy with the result of the surgery, either.
Some private clinics advertise that they can perform major operations such as breast enlargements or hernia repair under local anaesthetic with a sedative or sedation, however, this might not be as comfortable or safe as they claim. You might be in pain during the operation but unable to remember it afterwards because of the effects of the drugs. The clinic might use dangerously high levels of local anaesthetic, or dangerously high levels of sedation to put you into a deep level of unconsciousness equivalent to general anaesthesia. In 2016, the NSW Health Care Complaints Commission took action against a major cosmetic breast surgery clinic in Sydney for these practices (and for falsifying medical records). It ordered the clinic to perform the operations under general anaesthetic in licensed facilities instead.
Detailed Information - Regional Anaesthetic (other than a spinal block or epidural):
For regional anaesthetic, an anaesthetist numbs a large part of your body by injecting local anaesthetic near the nerves that affect the area (e.g. for an operation on your arm, he or she will inject it into your underarm). Sometimes people refer to it as 'local anaesthetic' since it uses the same drugs. Sometimes they call it a ‘block’ or similar: ‘regional block’, ‘peripheral nerve block’, ‘anaesthetic nerve block’ or ‘nerve block’. If it’s for your leg it can be called a ‘femoral nerve block’ and if it’s for your arm or shoulder it can be called a ‘brachial plexus block’.
It can be used for a variety of different types of surgery if the anaesthetist is skilled enough. For example, it could be used for an operation on your face, shoulder, arm, hand, ribs, groin, buttocks, thigh or ankle. However, it's not possible to use it for all types of surgery.
Regional anaesthetic takes time to administer. If you're nervous, you can have a sedative to help you relax - note that it will also cause memory loss afterwards. The anaesthetist will need to find the exact location of your nerves before administering the anaesthetic, and can use an ultrasound machine to do so (in the past, a nerve stimulating device was used). He or she will wipe the area with antiseptic and then inject the drug. You may feel ‘pins and needles’, tingling or pain, and then part of your body will go numb and you will be unable to move it. It takes about 20 minutes for the anaesthetic to become completely effective. The anaesthetist will use a pin, ice, or cold spray to check that you can’t feel any pain in the area to be operated on. You will still be able to feel pressure and movement because the anaesthetic doesn’t affect the nerves that transmit those sensations.
Occasionally (1 – 10% of the time) regional anaesthetic is unsuccessful e.g. it doesn't completely numb the area that’s going to be operated on. It might be possible for the anaesthetist to repeat the anaesthetic, inject some additional local anaesthetic near the area where the sensation is or give you painkillers. However, sometimes the only options are to have general anaesthetic or cancel the operation.
Anaesthetists don’t always warn that regional anaesthetic could be unsuccessful, and might give the impression that it’s guaranteed to work. You could be lying in the operating theatre with everything prepared for the surgery only to find out that the anaesthetic hasn’t been effective and have to make a hasty decision about what to do, without adequate discussion.
If the regional anaesthetic is successful then you can remain conscious throughout the operation. However, it's possible to become very nervous when the operation is about to start. It's easy to have doubts about the power of the anaesthetic, especially when you can still feel staff members moving the body part around. You could have a sedative, or an additional dose of it, to cause relaxation or drowsiness (and memory loss). Or you could have sedation or general anaesthetic to become unconscious.
During the operation, the anaesthetist might give you a variety of drugs by IV e.g. antibiotics, anti-inflammatory drugs or painkillers. Paracetamol might be included because it increases the painkilling effects of other drugs.
Regional anaesthetic lasts for a number of hours - even up to 24 hours - so it provides excellent pain relief for a time after the operation finishes. It wears off gradually, and then you might need to be given painkillers. Sometimes, the anaesthetist will leave a tube in you to continue to give you local anaesthetic for pain relief for a longer period of time, even for several days.
As with all types of anaesthetic, regional anaesthetic carries a small risk of side effects, injury and even death. It's more risky than local anaesthetic. Some websites claim that it's safer than general anaesthetic while others claim the opposite. Although the list of potential problems sounds alarming, you might not experience any of them, or might experience only minor ones. Also, it might be preferable to take the risk of anaesthetic than to leave the medical problem untreated.
Uncommon problems: pain and bruising at the injection site.
Rare problems: an infection, an allergic reaction, lung problems, heart problems, damage to blood vessels or muscles or nerves. Nerve damage causes some numbness, weakness or pain in an area and is usually temporary, healing within a few days to several months, but occasionally is permanent.
Very rare problems: a heart attack or seizure.
Detailed Information - Spinal Block:
A spinal block is a special type of regional anaesthetic where an anaesthetist injects local anaesthetic and sometimes painkillers into your back to numb your lower body from the waist downwards. It can be called ‘a spinal’, ‘spinal anaesthesia’, ‘subarachnoid anaesthesia’, ‘subarachnoid block’ (SAB), ‘true spinal’ or ‘intrathecal anaesthesia’. Like an epidural, it's a type of ‘neuraxial anaesthesia’, ‘neuraxial blockade’ or ‘neuraxial block’. It’s similar to an epidural in many ways, and patients often get the two confused.
It's generally used for surgery below the level of your belly button, such as for your foot, leg or lower abdomen. It's often used for prostate surgery. It's also often used for a caesarean section. It prevents pain and also prevents your muscles from reacting to the surgery. It's not usually used for operations higher up on your body because of a risk of spinal cord damage, breathing problems or other problems.
A spinal block can also be used for pain relief during natural childbirth, in which case, drugs can be used that still allow you to feel contractions and move around in bed.
Some patients can’t have a spinal block because of a medical problem such as low blood pressure, a bleeding disorder, an infection, a previous allergic reaction to local anaesthetic or a back problem. Patients also can’t have one if they’re taking particular types of blood-thinning medication. Your anaesthetist can determine whether it’s safe for you to have a spinal block.
Administering a spinal block involves a number of steps. The anaesthetist might give you a sedative first to help you relax, and it will cause some memory loss too. Before the block, you'll need to either sit curled forward with your back rounded or lie on your side with your knees pulled towards your chest. It can feel awkward, but it opens up the spaces in your back where the drugs will be injected. You'll need to remain completely still while it happens. The anaesthetist will wipe your back with antiseptic lotion and then inject a small amount of local anaesthetic into your lower back near your spine. He or she will temporarily insert a needle there, which you shouldn’t feel, and use it to inject more local anaesthetic, and sometimes painkillers, into the fluid that surrounds your spinal cord (cerebrospinal fluid - CSF).
You will feel ‘pins and needles’ and tingling, your bottom will become warm, and you will gradually become numb. The numbness will rise slightly up your abdomen and also descend all the way down your legs to your feet. It starts within 5 minutes but takes up to 30 minutes to become completely effective. The anaesthetist will use a pin, ice or cold spray to check that you can’t feel any pain in the area to be operated on. You will still be able to feel staff members moving your legs or lower body, because the anaesthetic only affects the nerves that transmit pain and not the ones that transmit movement.
As with other types of regional anaesthetic, 1-10% of the time a spinal block isn't completely successful and doesn't numb all of the area to be operated on. The anaesthetist might be able to repeat the injection, move you around to make the drug spread out more, administer additional local anaesthetic to another area of your body or give you painkillers. However, sometimes none of these options are possible or safe e.g. repeating the injection might cause the block to rise too high up your body and interfere with breathing. The only options might be to have general anaesthetic or cancel the operation.
Another potential problem is that a spinal block can start to wear off during an operation, particularly if the surgery takes an unexpectedly long time. The block has a limited duration: 1.5 hours to 4 hours. The longer timeframes are more likely if the anaesthetist had included painkillers during the injection as that increases its duration and effectiveness. If the block does start to wear off, it’s not possible for the anaesthetist to give more of the spinal block drugs. He or she can give painkillers or local anaesthetic, but if they’re ineffective then you will need to have general anaesthetic.
Anaesthetists don’t always warn that a spinal block might not be effective or last throughout the operation, and might give you the impression that it’s guaranteed to work. If it's unsuccessful, you could end up having general anaesthetic without adequate discussion about it.
If a spinal block is successful then you can remain conscious throughout the operation. However, that can be frightening. If you're very nervous, you could have a sedative, or an additional dose of it, to become relaxed or drowsy (as previously stated, it also causes memory loss). Or you could have sedation or general anaesthetic to become unconscious instead.
During the operation, the anaesthetist might give you a variety of drugs by IV such as antibiotics, anti-inflammatory drugs or painkillers. He or she might include Paracetamol because it increases the painkilling effects of other drugs.
As the spinal block wears off, you will gradually regain sensation, starting from your lower abdomen and continuing down your legs to your feet. You might feel ‘pins and needles’ or tingling. It can take a couple of hours to wear off completely. If the anaesthetist included painkillers with the spinal block, it helps with pain relief for up to 24 hours.
You might need to be given oxygen (though a tube in your nose or a mask) for up to 24 hours after having a spinal block because the drugs can lower the amount of oxygen in your blood.
As for all types of anaesthetic, a spinal block has a small risk of side effects, injury and even death. Some websites claim that a spinal block is safer than general anaesthetic (particularly for higher risk patients) while others claim that both are equally safe. The list of risks of a spinal block can sound alarming, however, you might not experience any problems or have only minor problems. It could also be better to take the risk of anaesthetic than to leave the medical problem untreated.
Possible problems: nausea, itching (on your face or body) or a feeling that you can’t breathe even when you can. That can happen if the block numbs your abdomen and chest wall so that you don't feel the normal sensations of breathing. Since the staff members will be monitoring your blood's oxygen level throughout the operation, they can tell if you're getting enough air.
Less common, more serious problems: an infection, poor blood clotting, a drop in blood pressure, a real problem with breathing, weakness in your arms, pressure on your brain (from various causes), a heart problem or a loss of consciousness. Some of these things can occur if the block rises too high up your body after it's administered and affects muscles that it shouldn't affect.
After the spinal block wears off, it’s possible to have an unpleasant side effect such nausea, itching or severe headaches. The headaches occur if the needle used for the injection accidentally created a small hole in the membrane around your spinal cord, allowing some cerebrospinal fluid to leak out. They’re worse when you’re sitting or standing (due to gravity) and somewhat better when you’re lying down. They start within a few days and last for several days or even weeks. Your body will eventually heal the hole. You can have treatment to help.
There's a small possibility of nerve damage from a spinal block. Usually it’s temporary, lasting a number of days or weeks. It can cause numbness, a ‘pins and needles’ sensation, pain or muscle weakness. However, there's a very rare risk of permanent nerve damage causing paralysis of one of your limbs or loss of control of your bowel or bladder.
Most patients don't have any problems. You have to decide for yourself whether it's worthwhile taking the risks in order to have the surgery.
Detailed Information - Epidural:
An epidural is a special type of regional anaesthetic where an anaesthetist inserts a catheter (plastic tube) into your back and then uses it to administer drugs such as local anaesthetic and painkillers. The catheter is left in place to continue giving you drugs for as long as necessary. An epidural can also be called ‘extradural anaesthesia’. Like a spinal block, it's a type of ‘neuraxial anaesthesia’, ‘neuraxial blockade’ or ‘neuraxial block’. Since it's similar to a spinal block, patients often get the two confused.
It can be used for various types of surgery, including operations that are expected to take a long time (where a spinal block wouldn't be possible). It can be used for an operation on some parts of your body below the head, and is often used for surgery on the lower parts of the body. The drugs prevent pain and also prevent your muscles from reacting to the surgery. It can't be used for all operations.
An epidural can also be used to provide pain relief after an operation for many hours or even for several days.
It's also often used for pain relief during natural childbirth, in which case, the drugs and dosages used won't completely numb everything or prevent you from moving your legs. Most of the information about epidurals online is in relation to childbirth.
Some patients can't have an epidural because of a medical problem. The reasons are similar to the ones that can prohibit a spinal block: low blood pressure, a bleeding disorder, an infection, a previous allergic reaction to local anaesthetic or a back problem. Patients also can’t have an epidural if they’re taking particular types of blood-thinning medication. Your anaesthetist can determine whether it’s safe for you to have an epidural.
The procedure is similar to that of a spinal block. The anaesthetist might give you a sedative first to help you relax (it also causes memory loss). You'll need to either sit with your back arched or lie on your side, curledd up. The anaesthetist will wipe your back with antiseptic lotion, inject some local anaesthetic and then temporarily insert a needle near your spine. It goes into a slightly different area than it does for a spinal block: just outside of the membrane that contains cerebrospinal fluid. The level it’s inserted at depends upon which area of your body needs to be numbed. Sometimes, the anaesthetist will use ultrasound or fluoroscopy to help guide the needle. He or she will thread a catheter through the needle, tape the catheter to your back and then use it to give more local anaesthetic and painkillers.
The drugs will cause you to feel warm and numb. The anaesthetist can control how much feeling you have by the amount, strength and type of drugs. If you're going to have surgery then he or she can use a pin, ice or cold spray to check that you can’t feel any pain in the appropriate area. An epidural can take 20 to 30 minutes to become fully effective.
As for other types of regional anaesthetic, there’s a 1 – 10% chance that an epidural won't be completely effective. It can be patchy or incomplete. The anaesthetist might be able to solve the problem by moving the catheter or by inserting a second one, but sometimes it's not possible to fix it. If you’re giving birth, the anaesthetist can give you additional painkillers. If you’re going to have surgery, painkillers might not be sufficient and the only options might be to have general anaesthetic or cancel the operation. The anaesthetist might not warn you beforehand that there's a risk of the epidural not being effective.
With an epidural, you can remain conscious during the operation or childbirth. If you're too nervous, the anaesthetist can give you a sedative, or an additional dose of it, to become relaxed or drowsy (it will also cause memory loss). For an operation, you can have sedation or general anaesthetic to become unconscious.
The anaesthetist will continue to administer drugs through the catheter throughout the process, so there's no danger of the epidural wearing off part-way through. The anaesthetist might also give you other drugs by IV such as antibiotics, anti-inflammatory drugs or painkillers. Paracetamol might be included because it increases the painkilling effects of other drugs.
After the operation or childbirth is over, the anaesthetist might stop the epidural, in which case the numbness will wear off over a few hours. Alternatively, you might continue to receive drugs at low doses for pain relief for hours or even days.
You might need to be given oxygen (though a tube in your nose or a mask) for up to 24 hours after an epidural because the drugs used can lower the amount of oxygen in your blood.
As for all types of anaesthetic, an epidural has a small risk of side effects, injury and even death. Some websites claim that it's safer than general anaesthetic for surgery and others claim that both are equally safe. It's mentioned as having the same level of safety as a spinal block. The list of risks can sound alarming, but you might not have any problems at all or might have only minor problems. It could be better to take the small risk of having an epidural than to leave the medical problem untreated or go through the pain of natural childbirth.
Possible problems: nausea, vomiting, itching, dizziness, difficulty urinating, backache or other pain.
Less common, more serious problems: low blood pressure, an infection, an allergic reaction, difficulty in moving your arms or legs, a breathing problem, a heart problem, a seizure, blood clots around your spine or nerve damage. There is an extremely rare risk of permanent paralysis.
Most patients don't experience any problems having an epidural. You can decide whether it's worthwhile taking the risks.
Detailed Information - Combined Spinal Epidural:
A Combined Spinal Epidural is when an anaesthetist performs both a spinal block and an epidural at the same time. It can be abbreviated to CSE. It combines the benefits of a spinal block - such as speed and effectiveness - with the ability to prevent pain for a long period of time using an epidural. It avoids some of the disadvantages of both. It's a complicated technique.
It can be used for surgery (including a caesarean section) or natural childbirth.
The anaesthetist will insert a needle into your back and then use it to first inject drugs for a spinal block and then insert a catheter to administer drugs for an epidural.
It might not be possible to perform a spinal block first then later make another injection for an epidural because of a risk of nerve damage.
See the sections on spinal blocks and epidurals for more information about them.
Detailed Information - General Anaesthetic:
General anaesthetic is a deep level of controlled unconsciousness caused by a combination of drugs given by IV and\or gas. You’ll be unaware of everything, won’t feel any pain, won’t respond to anything and will lose your usual reflexes. People often call it ‘sleep’ as a euphemism or simplification, however, it's different from sleep and you won't feel rested afterwards. It's also called a ‘general’ or abbreviated to ‘G.A.’ on medical records. If it’s given by IV only, it can be called Total Intravenous Anaesthesia, TIVA. Sometimes, general anaesthetic is called ‘light general anaesthetic’.
It can be used for any type of operation. There are many types of surgery that can only be done under general anaesthetic such as bowel, heart and lung surgery.
Your experience of it will usually be straight-forward. The anaesthetist might give you a sedative first to help you relax and reduce anxiety. That also causes some memory loss. He or she will ask you to wear a face mask to breathe in air and give you drugs by IV which will cause you to feel drowsy and then drift off into unconsciousness within a minute. (A gas can be used to do this but it can smell bad or be uncomfortable.) You might dream briefly as you’re slipping off into unconsciousness.
The next thing you know, you’ll be waking up very slowly, possibly dreaming as you do so. You might feel very cold. You'll be in the recovery room and wearing a face mask again. Patients are often surprised when a nurse tells them that the operation's been done because they feel like they're still waiting for it to start. No matter how long it took, it will seem as if almost no time has passed, which is disconcerting. You’ll probably feel the same way emotionally as you did before you were given the anaesthetic, however, a small percentage of patients cry as a side effect of it. You probably won’t remember becoming drowsy or falling unconscious and if you were given a sedative first, you might not even remember having been taken into the operating theatre.
For about 24 hours afterwards you’ll feel groggy and find it difficult to think clearly or concentrate on anything, might have a sore throat and might not have as good reflexes as usual. It’s best to have someone stay with you during this time. You mustn’t drive vehicles, operate any machinery, make important decisions, sign any legal documents, travel alone, travel to remote areas or do anything that requires a clear mind or good reflexes. Some hospitals will advise you to avoid doing these things for 48 hours.
Further explanation of the general anaesthetic drugs and procedures:
Usually, the anaesthetist will give you a drug by IV to cause unconsciousness and then a gas to maintain it. The drugs and gases are called 'hypnotics'. The gases are also called ‘volatile gases’, ‘volatile anaesthetic agents’, ‘volatile agents’ or ‘volatile anaesthetic’ and can be noted on medical records as just ‘volatile’. The higher the doses of drugs, the deeper the level of unconsciousness they will cause and therefore the more effective they will be at preventing you from experiencing pain. Most of your brain will be inactive while under general anaesthetic.
There are a few choices of drugs. Propofol (Diprivan) is often given by IV to cause unconsciousness. Its effect lasts for about five minutes. Sevoflurane and Desflurane are gases that are commonly used to maintain unconsciousness. (In the past, Isoflurane was frequently used.) A gas can be mixed with either nitrous oxide and air, or air only. Each anaesthetic machine provides a choice of at least two anaesthetic gases in addition to nitrous oxide.
While you're unconscious your throat muscles relax, so the anaesthetist has to put a plastic tube (often called an ‘airway’) into your throat to allow you to breathe, and will tape part of it to your face. The other end will be connected to the anaesthetic machine. If the anaesthetist uses a gas then it will be given through the tube.
A commonly used type of tube is an endotracheal Tube (ETT) which goes all the way down your throat and past your vocal cords to the entrance to your lungs. Sometimes, the anaesthetist will put it in before you fall unconscious, in which case, he or she will use drugs such as local anaesthetic and painkillers to insert it. Often, the anaesthetist will put it in after you're unconscious and will administer a paralysing drug - a paralytic - (either short-acting or long-acting) to be able to push it past your vocal cords.
Another type of breathing tube that can sometimes be used is a shorter one called a laryngeal mask airway (LMA) which goes down your throat and near, but not past, your vocal cords. The anaesthetist doesn't need to use paralytics to insert it. It’s less invasive and irritating than an ETT and less likely to cause a sore throat, however, many patients can’t use it: pregnant women, some diabetics, obese people, people who’ve eaten recently and people who have serious reflux problems. There are also many types of operations where it can’t be used e.g. surgery lasting longer than a few hours, surgery where you’re lying face-down, surgery in the nose or mouth and surgery where breathing must be carefully controlled (such as brain, heart, chest or lung surgery).
Your eyes don’t remain completely shut while you’re unconscious and you can’t blink, either. The anaesthetist will tape them shut to protect them. He or she might put some lubricant in them first to prevent them from drying out.
The anaesthetist will probably give you a variety of drugs by IV such as antibiotics, anti-inflammatory drugs, drugs that cause memory loss, painkillers (including Paracetamol, which increases the effects of other painkillers) and possibly paralytics. Although being deeply unconscious prevents you from experiencing pain and basically keeps you still, painkillers and paralytics prevent your body from reacting to the surgery e.g. by twitching your muscles, causing your muscles to pull a limb back or increasing or decreasing your heart rate, blood pressure, temperature etc.
If you’ve had a successful local or regional anaesthetic, spinal block or epidural and are having general anaesthetic simply to be unaware of what’s going on then it requires only a limited number of drugs and the hypnotics will probably be low doses, causing a relatively light level of unconsciousness (still deeper than sedation, however). Paralytics won't be needed (other than for inserting an ETT).
If you’ve had a regional anaesthetic, spinal block or epidural that hasn’t been completely effective then the general anaesthetic needs to provide additional pain prevention as well as unawareness. It might also need to prevent your body from responding to the surgery. It may require a wider range of drugs and the hypnotics will be at higher doses. Paralytics might be needed during the surgery (not just for inserting an ETT).
If general anaesthetic is the only anaesthetic you're having for an operation then it requires a wide range of drugs and the hypnotics will be at high doses. Paralytics might be needed during the surgery (not just for inserting an ETT).
Paralytics completely paralyse all of the muscles in your body – including the ones used for breathing – except for your heart. (Very high levels of anaesthetic gases can achieve the same effect, and that’s what was often used in the past.) Paralytics are also euphemistically called ‘muscle relaxants’ or called ‘neuromuscular blockade’, ‘neuromuscular blocking drugs’ or NMDB. Commonly used drugs include the short-acting drug Succinylcholine (also called Suxamethonium, Suxamethonium Chloride or, colloquially, ‘Sux’) which is often used to put an ETT tube in, and longer-acting drugs such as Vecuronium, Rocuronium (Zemuron) and Cisatracurium (Nimbex). Less commonly used drugs include Pancuronium, Atacurium and Mivacurium. The drug names often end in ‘onium’ or ‘urium’, unlike other drugs used for anaesthesia.
For some operations paralytics are desirable and for others they are essential. Some surgeons ask the anaesthetist to use them for every operation because they believe that it results in better conditions for operating. Types of operations where they are used include abdominal surgery, orthopaedic surgery, throat surgery and chest surgery that affects the heart or lungs. It’s difficult to find information on what types of operations paralytics are essential for (as opposed to desirable) but they include laparoscopy, delicate neurosurgery, ear surgery and eye surgery.
Often, you can’t breathe on your own during general anaesthetic. The most common reason is that the anaesthetist uses paralytics. Another possible cause is high doses of some types of painkillers. A less common reason is that you’re at such a deep level of unconsciousness that your brain can no longer control your breathing (either because the anaesthetist put you into this level deliberately or because you unintentionally slipped into it).
If you can’t breathe on your own then a ventilator, which is part of the anaesthetic machine, breathes for you by pushing air (and probably anaesthetic gas) in and out of your lungs through the breathing tube. It can be set to monitor your breathing and take over only at times that you stop breathing, or it can be set to completely control your breathing throughout the operation. If a ventilator fails or can’t be used for some reason, nurses can keep you alive by doing manual ventilation with a 'bag', squeezing air into your lungs regularly.
After the operation is over, the anaesthetist will follow a number of steps. He or she will stop giving you anaesthetic gases and other drugs. If paralytics were used then he or she will give you drugs to reverse the effects so that you are no longer paralysed. He or she might also need to reverse some types of powerful painkillers because of their undesirable side effects. You will be able to breathe on your own again. The anaesthetist will remove the tape from your eyes and remove monitoring devices. He or she will remove the breathing tube, either while you’re still unconscious (in which case, he or she might temporarily put in a shorter, rigid plastic tube called a Guedels’ Airway to help keep your throat open) or in 5 - 15 minutes time, after you’ve started regaining consciousness.
The anaesthetist and other staff will take you to the recovery room. Nurses will put a face mask on you for you to breathe through and will check you regularly. Regaining consciousness (usually called ‘waking up’) is a slow, gradual process. Some websites state that patients can be awake enough to open their eyes and talk only 5 – 10 minutes after the anaesthetist has stopped giving them drugs. However, they usually don’t remember it later because of the drugs causing memory loss. Other patients take 30 – 60 minutes to reach that stage. The nurses will mark your progress in the medical records (e.g. a score of 0/2 for complete unconsciousness then 1/2 for partial consciousness, then 2/2 for complete consciousness). There’s nothing that staff can do to speed up the process. If something went wrong (e.g. if the anaesthetist made a mistake with the anaesthetic, or there was a medical problem), you could remain unconscious for a number of hours.
No matter how long the operation took and how long you were unconscious for, you won’t have any sense of how much time has passed. Presumably, this is because your brain is very inactive under general anaesthetic and, unlike during sleep, doesn’t monitor light, sound, touch, pain etc and doesn’t cause you to dream (other than briefly while going under or coming out of it). Time is a series of changes but under general anaesthetic your brain doesn’t register the changes.
Sometimes anaesthetists use the term ‘light general anaesthetic’, but there doesn’t seem to be any standard definition of it. It appears to refer to the anaesthetist using lower doses of drugs so that you’re at a somewhat less deep level of unconsciousness (although still deeper than that caused by sedation). It might also mean that paralytics aren’t required and that you’re able to breathe on your own during the operation.
Different doses of drugs are needed by different patients, or even by the same patient on different occasions, so it’s difficult for anyone to tell from studying your medical records how deeply unconscious you were or whether it would be appropriate to call the anaesthetic ‘light general anaesthetic’. Websites and books usually don’t use the phrase at all, and medical records just show ‘general anaesthetic’ or ‘G.A.’.
General anaesthetic, like all types of anaesthetic, has a small risk of side effects, injury and even death. The risks can sound alarming but you might not experience any of them or experience only minor problems. It might be better to take the small risk of having anaesthetic than to leave the medical problem untreated.
Uncommon problems: bruising and soreness, nausea, vomiting, a dry mouth, a sore throat, aching muscles, a headache, itching, feeling cold, difficulty urinating, dizziness, small cuts to your lips or tongue or some damage to your teeth.
Rare problems: an infection, an allergic reaction, breathing problems, damage to your eyes, nerve damage (usually temporary), damage to your vocal cords or larynx from the breathing tube, pneumonia, lung damage from a ventilator, confusion or memory problems for days or weeks afterwards (mainly in elderly people), a heart attack, a stroke, kidney failure, liver failure, paraplegia, quadriplegia or brain damage.
Extremely rare problems: sometimes a patient goes under general anaesthetic and never wakes up again. This mainly happens to patients who are already seriously ill or injured. The risk increases the longer that a patient's affected by the anaesthetic drugs. Sometimes a patient dies. A website run by the Australian Society of Anaesthetists suggests that the risk of dying from general anaesthetic alone is 1 in 185,056 or even less for a fit, healthy patient up to middle-age having straightforward elective surgery (less than 1 in 250,000). Different websites have different statistics, and some list the risk as being higher. However, usually when a patient dies during an operation it's because of his or her medical problems or the surgery itself. Anaesthetic usually isn't even a contributing factor.
Another risk of general anaesthetic is experiencing anaesthetic awareness, also called ‘unintended intraoperative awareness’. It means not remaining completely unconscious throughout the operation and can happen if the anaesthetic machine is faulty. It can also happen if you aren’t given enough of the drugs, which could be because it would be too dangerous for you, because the anaesthetist makes a mistake or because you’re somewhat resistant to the drugs. Different websites give different probabilities of anaesthetic awareness, ranging from 1 in 500 to 1 in 23,000. It’s more likely to happen during heart surgery, thoracic surgery, a caesarean section or emergency surgery, because lower doses of anaesthetic drugs are used, for safety. (Higher doses could affect your heart too much, or in the case of a caesarean section could affect the baby too much.)
Often when patients believe that they’ve experienced anaesthetic awareness they’re mistaken. They might mistake a dream they had while going under the anaesthetic or coming out of it for awareness, or they might remember things from the recovery room while regaining consciousness. Also, many patients who believe that they had general anaesthetic actually had only local or regional anaesthetic with sedation which caused partial memory loss.
Sometimes patients really do experience anaesthetic awareness under general anaesthetic. It usually happens at the beginning or the end of the operation, and usually lasts for less than five minutes. However, it can last for longer, or even for the entire operation. You might hear machines beeping, hear staff talking or moving, or feel touch or pressure. You might feel like it’s extremely difficult to breathe. There’s a small chance that you’ll feel pain, which could be minor (such as a sore throat) or major (such as pain from the surgery itself).
The anaesthetist should be able to tell that you’re experiencing anaesthetic awareness and solve the problem. If he or she didn’t use paralytics then you can move or make a sound to gain attention. However, if paralytics were used then you will be completely paralysed and unable to do anything – a terrifying scenario. The anaesthetist should still be able to tell that you’re experiencing awareness by noticing your heart rate increasing (for anything other than heart surgery) or by monitoring your other vital signs such as blood pressure. Sometimes specialised brain monitoring equipment can be used, especially if you’re at a higher risk of experiencing awareness. The anaesthetist should be able to give you more drugs to send you unconscious again. However, some anaesthetists have the attitude that they should just give you drugs to prevent you from remembering the experience afterwards, as if somehow it doesn’t matter that you’re suffering as long as you don’t remember it later on.
Unfortunately, there are extremely rare cases where a patient initially falls unconscious, becomes paralysed from paralytics, but then regains consciousness and goes through the entire operation paralysed and in excruciating pain. The anaesthetic machine might fail and not deliver anaesthetic gases correctly or at all. It’s a nightmare situation, one that no person should ever experience – but it does happen. A website run by the Australian Society of Anaesthetists acknowledges it and discusses it. Every now and then there’s a report of it in the media.
Patients who have experienced anaesthetic awareness and remember it afterwards can suffer psychological problems such as anxiety, sleep disturbances, nightmares, flashbacks, panic attacks, depression or Post-Traumatic Stress Disorder (PTSD).
Although general anaesthetic has risks, tens of thousands of patients have it every year in Australia and most of them don’t experience any problems, or have only minor problems.
Detailed Information - Sedatives and Sedation:
A sedative is a drug that slows your brain activity to cause sedation: relaxation, drowsiness or a light level of unconsciousness that's often called 'sleep'. The effect depends on which drug is used and the dose given. A sedative also causes partial or total memory loss. It can be administered by an anaesthetist, doctor or nurse. It can be called an ‘anti-anxiety drug’ or a ‘premed’.
Websites use different terms for sedation. They can refer to different levels: minimal sedation, moderate sedation or deep sedation (which is not as deep a level of unconsciousness as in general anaesthetic). They can use other terms: ‘procedural sedation’, ‘conscious sedation’ (which, however, doesn't always involve remaining conscious), ‘twilight anaesthesia’, ‘twilight sleep’ or ‘monitored anaesthesia care’ (MAC). The definitions of these can vary a little. Some websites deny that sedation ever involves unconsciousness and claim that it's sleep instead. However, it’s an unnatural, drug-induced state, and you won’t wake up until after the drugs have worn off. If someone shakes you, you might respond by mumbling.
Sedation is used to reduce stress and anxiety so that it’s easier for you to get through the unpleasant experience of an operation or other medical procedure. Everyone has natural instincts that cause them to try to avoid injury. Rationally, you know that the operation or procedure will help you but because it involves your body being cut into or manipulated, your natural instincts cause you to be frightened and want to avoid it. Sedation can help you overcome the fear.
If you're sedated to the point of unconsciousness then you won't be aware of what's happening. Even if you drift in and out of consciousness, you'll remember little or nothing afterwards. You will still be able to breathe on your own and won't need to have a breathing tube in your throat.
Sedation isn’t always essential for medical reasons, so you should have a choice as to whether to have it or not. However, staff members sometimes give the impression that it’s compulsory.
It doesn't prevent you from experiencing pain - even if you're unconscious, you won't be at a deep enough level for that - so it's used in conjunction with anaesthetic for surgery. If you're going to have local or regional anaesthetic then the anaesthetic needs to be given while you're still conscious so that the anaesthetist can confirm its effectiveness with you. You might have an initial dose of a sedative to help you relax, be given the anaesthetic, then be sedated further to become unconscious.
Sedation can be used by itself for unpleasant non-surgical procedures such as setting a fracture, draining an abscess or having an endoscopy. (Dentists also use it for dental treatment.) However, you could still be in discomfort or pain at the time even if you can’t remember it afterwards, so it’s questionable if it’s always ethical.
Sedation can be given by IV, an injection, gas or pills. One commonly used sedative is Midazolam, which is from the same family of drugs as Valium and is given by IV. A low dose causes relaxation, a higher dose causes drowsiness and a higher dose still causes unconsciousness. The effects last from one to six hours. Unconsciousness can also be achieved with a low dose of a drug usually used for general anaesthetic such as Propofol (Diprivan). Propofol’s effects last for only five minutes or so, so repeated doses are given by IV at regular intervals.
The memory loss you'll experience is unnatural and unusual. If you're conscious you’ll be aware of what’s happening but not all of your perceptions, thoughts and feelings will be added to your long-term memory. Time will feel like it’s passing by very quickly. After the sedative wears off, you will have gaps in your memory (which you might not be aware of), only have faint fragments of memory or not be able to remember anything at all (in which case, you might mistakenly believe that you had been unconscious). The higher the dose of the sedative, the worse the memory loss will be. You might not even remember having gone into the operating theatre.
It can also cause retrograde amnesia, that is, it can prevent you from remembering something that happened just before it was given. You might not remember the medical practitioner telling you that he or she was going to administer the drug, or remember it happening.
Anaesthetists and other medical staff members usually don’t warn patients of the memory loss. They're expected to warn of likely risks and side-effects of anaesthetic but don't seem to regard that as applying to sedatives too. Nor do they remind patients afterwards of things that the drug might have caused them to forget.
A sedative also affects your decision-making ability so that you’re more likely to agree to something that the anaesthetist, surgeon or other medical practitioner suggests. You might agree to an additional procedure, or to have general anaesthetic if you were originally going to have only local or regional anaesthetic. The situation isn’t truly informed consent, yet staff members act as if it is. Afterwards, you might not remember what happened or why. People can be mistaken for years or decades about what type of anaesthetic they had and whether or not they had been unconscious.
Sedation will wear off gradually after the medical practitioner stops giving you the drug. However, it will continue to affect your judgement for at least 24 hours afterwards so you might not be able to drive a vehicle, operate machinery, sign legal documents or make important decisions during this time.
Sedation has risks, as all types of medical treatment do. Possible problems include: a headache, nausea and vomiting, itching, shivering, sore\dry throat and lips, slower breathing, dizziness, low blood pressure, a heart problem or aspiration.
There are less common problems such as weakness or an allergic reaction.
Rare problems include nerve damage, a blood clot in the leg, a heart attack, a stroke, a seizure or brain damage.
Although the list of risks sounds alarming, you might not experience any of them or have only minor problems. Sedation might enable you to have an operation or procedure that you would otherwise be too nervous to go through.
Making Complaints:
If you’re unhappy with the information the anaesthetist provided (or didn’t provide), the way that he or she acted, the effectiveness of the anaesthetic or other aspects of your care, you can take action.
Options include:
- Asking the hospital for a copy of your medical records to learn more about what happened.
- Contacting the anaesthetist (e.g. via the hospital) to discuss the matter.
- Providing feedback or suggestions to the hospital or local health district organisation.
- Making a complaint to the hospital or local health district organisation.
- Making a complaint to an official agency. The Australian Health Practitioner Regulation Agency (AHPRA) website has a list of organisations in different states and territories, or it may be appropriate to make a complaint to the AHPRA itself.
- Talking to a lawyer about suing the anaesthetist or hospital for medical negligence or assault, if applicable. However, lawsuits are very expensive.
- Writing about your experiences to warn other potential patients.
Note that taking one action may have an effect on whether you can take another. If you make a complaint, the anaesthetist might not want to talk to you directly. If your complaint is to an official agency, the hospital or local health district organisation may regard it as a legal issue and refuse to discuss the matter further. If you sue the anaesthetist or hospital, everyone may refuse to talk to you, and an official agency may not be able to accept a complaint from you because of their policies.
If you make a complaint, it’s important to say what you would like to happen, e.g. an explanation or apology. People are wary about possible lawsuits and may not reply if they believe that you’re considering legal action.
Regardless of what actions you take, the anaesthetist, hospital or local health district organisation may not want to admit the truth about your allegations. Their main concerns may be to protect their reputation and avoid legal action. The anaesthetist might deny everything, only admit part of the truth, and/or give an alternative, inaccurate version of events. The hospital or local health district organisation may not put much effort into investigating your complaint, take the anaesthetist’s word of events over yours, or give an inaccurate account of the situation.
Even an official agency may not be as objective or put as much effort into investigating your complaint as you would like. An organisation consisting mainly of medical practitioners may be more inclined to take the anaesthetist’s side than yours.
Despite that, it’s still worthwhile making a complaint. The anaesthetist and/or hospital may apologise for your distress, even if they don’t acknowledge the truth. The anaesthetist and hospital staff may think about your allegations and consider acting differently in future or changing procedures, even they don’t tell you about it. The mere fact that you’ve made a complaint may act as a warning to them.
An official agency may make recommendations or suggestions to the anaesthetist or hospital. If they accept your word of events, they may caution or reprimand the anaesthetist, ask him or her to do further training, or take other action. If they don’t accept that your allegations are proven, they will still keep them on file and may look at them again if another patient makes a similar complaint in future.
These days, you can write about your experience online to inform and warn other prospective patients. You can post in message forums, on your own website, on friends’ websites, on Facebook, Google reviews etc. There are some websites set up specifically for patients to post about their experiences at hospitals and health organisations. They will generally allow you to name the hospital but not the anaesthetist.
There is an Australian website set up specifically for patients to review individual medical practitioners – including anaesthetists – however, it’s less useful than it appears to be. It won’t display a negative review unless the practitioner claims the profile and opts to make reviews publicly viewable, which he or she is unlikely to do if you’ve been critical.
You can try writing about your experience in an article to send to a magazine or anthology, however, even if they accept it for publication they probably won’t allow you to name the hospital or anaesthetist because of legal concerns.
Websites for Additional Research:
These websites have additonal information on anaesthetic. Note that some use the euphemism ‘sleep’ or ‘deep sleep’ for unconsciousness.
https://www.asa.org.au/ASA/Patient_information/Patient_information.aspx – a site run by the Australian Society of Anaesthetists.
http://allaboutanaesthesia.com.au/ – a site run by the Australian Society of Anaesthetists.
https://www.anzca.edu.au/patient-information – a site run by the Australian and New Zealand College of Anaesthetists.
https://www.betterhealth.vic.gov.au - a Victorian government health site - use the search function to search for 'anaesthetic'.
http://www.narcomed.com.au/ - a site run by Victorian anaesthetist Dr Mark Freedman.
My Experiences:
Experience 1: The dramatic effects of a sedative.
Over 20 years ago I had emergency surgery for a fracture at Sydney Hospital, which is a public hospital.
When the surgeon discussed the operation with me she said, “You can either have general anaesthetic and be unconscious during the operation or local anaesthetic with a sedative and stay awake.” I chose the latter. The anaesthetist discussed the risk of bruising or nerve damage from the anaesthetic injections, but didn’t say anything about the effects of the sedative.
My experience felt odd. I was taken to the anaesthetic room and the anaesthetist prepared to use a nerve stimulating device before injecting the anaesthetic. The next thing I remember, I was waking up slowly, feeling very cold. I was waiting to be taken into the operating theatre, but a nurse told me that the operation had already been done. I was taken to a ward to recover. For about 24 hours I was tired and had difficulty concentrating, and also had difficulty urinating.
I looked at my medical records the day after the operation, but didn’t understand much of them. The operating room nurses' report form had two sections that were ambiguously labelled\misprinted. A recovery room form said that I’d been unconscious when taken in there and had regained consciousness after 45 minutes. The nurses’ progress notes said that I’d had the operation done under ‘sedation anaesthetic with block’ and claimed that I'd been 'conscious on arrival', even though that was obviously incorrect.
For the next twenty years I assumed that I’d been given too much sedative and fallen unconscious by mistake, but then I decided to look into the matter. I obtained a copy of the medical records from the hospital to study them and I talked to the anaesthetist on the phone. I worked out that the sedative had caused memory loss from the point when he had been about to use the nerve stimulating device. He had successfully done a regional block and taken me into the operating theatre, but I had then become very nervous. He had offered to give me more sedative or to do general anaesthetic, and I had agreed to the latter. The anaesthetic nurse, Ms Feirson, had lied when filling out the progress notes afterwards. The anaesthetist didn’t know why.
I later emailed feedback and suggestions to Sydney Hospital. It seemed too late to make a complaint about Ms Feirson. The AHPRA website didn’t list anyone with that surname as currently working in any medical field in Australia. She might have changed her surname, changed to a non-medical career, moved overseas, retired, or passed away.
Experience 2: Cancelling an operation.
Just under 20 years ago I planned to have elective surgery at a private hospital in the northern suburbs of Sydney.
The surgeon was only willing to perform the operation under general anaesthetic. I had a consultation with the anaesthetist who would be treating me and he explained a number of risks, including ‘Sometimes people go under general anaesthetic and never wake up again.’ I also read about risks in medical books at the State Library.
When I was at the hospital for the operation, I became more and more nervous as the time for the surgery approached. I became extremely nervous when I was taken to the anaesthetic room. I believed that I’d never had general anaesthetic before. I kept thinking about the anaesthetist saying that sometimes patients didn’t wake up from it, and worrying that it would happen to me.
I told staff that I wasn’t sure if I wanted to go through with the operation. Nurses talked to me, and then the anaesthetist and surgeon came in and talked to me. They were all polite and respectful, although the surgeon was somewhat condescending. I asked to cancel the operation. The staff did so, and I was able to leave the hospital soon afterwards.
Not much happened after that. When I talked to the surgeon’s receptionist later, she was annoyed and disapproving at me having cancelled the operation. I had to pay some fees to the surgeon and to the hospital, however, the anaesthetist waived his fee.
Experience 3: Choice of anaesthetic.
A few years ago I had emergency surgery for a fracture at Westmead Hospital, which is a public hospital.
A doctor discussed the operation with me and tried to persuade me to have general anaesthetic. I was reluctant, and explained my concerns about it. (I still believed that I’d never had it, as it was before I looked into the Sydney Hospital operation.) She said that regional anaesthetic might be possible instead, and mentioned one or two minor risks and the rare risk of nerve damage. She asked me to sign a consent form for the operation even though we hadn’t agreed on the anaesthetic.
The next morning, I was taken to the anaesthetic room. I was very nervous and asked a nurse for something to help me relax but she refused, saying that I needed a clear mind to discuss anaesthetic options with the anaesthetist. When he came in he asked why I didn’t want general anaesthetic and I explained my concerns. He was willing to do a spinal block instead.
Staff then took me into the operating theatre and the anaesthetist performed the spinal block successfully. I became nervous again and asked him for something to help me relax but he refused because it might send me unconscious (which I didn’t want). I had some bad itching on my chest and he explained that it was a side-effect of the spinal block drugs. The bright lights of the operating theatre started to annoy me and I asked him to cover my eyes. I became relaxed and sleepy and dozed a little.
A day after the operation I developed severe headaches which lasted for three days then eased off over another four days. A doctor explained that it was a problem caused by the injection for the spinal block.
I thought that I had become relaxed and drowsy during the operation of my own accord. However, I eventually obtained a copy of my medical records from the hospital and also emailed the anaesthetist. After initially refusing to give me something to help me relax, he had compromised by giving me a low dose of a sedative. It caused retrograde amnesia so afterwards I didn’t remember him telling me about it or injecting it into the IV line near my wrist.
I later sent feedback and suggestions to the hospital and to the local health district organisation. I suggested, amongst other things, that patients be given a choice of anaesthetic.
Experience 4: Misinformed consent.
A few years ago I had elective surgery at Westmead Hospital, a public hospital. It was to prevent a serious medical problem from occurring in the future.
At a surgical consultation a doctor tried to persuade me to have general anaesthetic, which I was reluctant to have. (It was before I’d found out that I’d had it at Sydney Hospital all those years ago, so I still believed that I’d never had it.) He wasn’t sure if local or regional anaesthetic was possible. He asked me to sign a consent form for the surgery even though we hadn’t reached any agreement on the anaesthetic.
At a later date I had a consultation with an anaesthetist named David. He also tried to persuade me to have general anaesthetic and I explained my concerns, including some of the risks. The only one that he commented on was the risk of going under and never waking up again. He said that mainly happened to patients who were seriously ill or having major operations. However, he believed that an epidural should be possible instead. He said that if it wasn’t effective then general anaesthetic would be the only other anaesthetic option. He later talked to the anaesthetist assigned to the operation, Ian, and confirmed that I could have an epidural.
When I went to the hospital for the operation, I found out that Ian had changed his mind. He tried to insist on general anaesthetic and told me to go to a private hospital if I wanted a choice. I objected to general anaesthetic and mentioned a number of my concerns. He decided not to treat me and passed me onto another anaesthetist, Matt.
Matt asked why I didn’t want general anaesthetic and I again explained some of my concerns. The only one that he commented on was the risk of experiencing anaesthetic awareness during the operation, waking up paralysed and in pain. He said in that situation, a patient’s heart rate would increase (as an indicator). However, he was willing to do an epidural or spinal block instead, and decided on the latter.
He told me that when I’d had an operation the last time I’d been given an ‘anti-anxiety drug’ and asked if I wanted it again. That was before I’d looked into the matter, so I didn’t know what he was talking about. He didn’t explain about it causing memory loss. I didn’t agree to it, and he didn’t use it.
The spinal block wasn’t completely effective i.e. it didn’t rise high enough up my abdomen to cover the area to be operated on. Matt apologised and said that he’d had to be careful that it didn’t rise too high and interfere with breathing – a risk that I’d been unaware of. He said that perhaps we could wait for it to wear off then try again, but then said that it would be too late in the day by then.
He said, “Perhaps I can address your concerns about general anaesthesia” and “I can offer a part-general”. He said that I wouldn’t be paralysed, would be able to breathe on my own, and said, “I can put you in a sleep-like state instead of being unconscious. You won’t dream, but you’ll be in a sleep-like state.” I asked twice, “So I’ll be sleeping instead of unconscious?” and he said, “Yes” both times. He said that I’d wake up as soon as he stopped giving me drugs, while I was still in the operating theatre. When I asked if a face mask was just for oxygen, he said that he would give drugs only by IV. I agreed to what he had suggested. An anaesthetic nurse was the only other person present during the conversation, and she didn’t say anything.
Afterwards, I woke up slowly and saw that I was in the the recovery room. A nurse told me that the operation had been done. I worked out that almost an hour must have passed since it had finished. I was tired and had difficulty concentrating, and that continued for about 24 hours afterwards.
I had doubts about whether Matt had told the truth but thought that he might have used a sedative instead of normal general anaesthetic, and I might have been only drowsy during the operation but unable to remember it afterwards.
At different times I looked up information online, talked to the surgeon at a check-up, got a copy of my medical records from the hospital and sent a message through the local health district organisation’s complaints section via their website.
Matt - Dr Matthew Doane - had lied to me. He had used ordinary general anaesthetic. The only things he had told the truth about were that he hadn’t used paralytics and that I’d been able to breathe on my own during the operation – although the latter hadn’t even been guaranteed. The situation was, at best, misinformed consent.
I wasn’t happy with the response to my complaint. An emailed letter signed by a hospital executive apologised for my experience, but gave an inaccurate account of events. It claimed that Matt had discussed risks and options that he hadn’t discussed, didn’t acknowledge the misleading language he had used, and implied that procedures were done specifically for me when actually they were standard procedures. It inaccurately said that the initial dose of drugs by IV was ‘a very light dose’ and made a vague, misleading claim that I had been ‘at a very light state of anaesthesia’ at all times. It implied that the situation had been informed consent. It sounded like whoever had looked into the matter on behalf of the executive had asked Matt what had happened, taken his word for everything, and not talked to the anaesthetic nurse or anyone else. It also sounded like he or she was more interested in protecting the hospital than in acknowledging the truth.
When I tried to follow up on my complaint, staff were reluctant to respond. I sent two messages to the executive’s assistant and she said that they had been passed on to Matt, however, it later turned out that he had never received them. The executive didn’t reply until I sent another message through the local health district organisation’s complaints section. Then she apologised that the words Matt had used to describe his anaesthetic technique had led me to feel that I had been deceived. She said that Matt had changed jobs and no longer worked for Westmead Hospital and claimed that she couldn’t contact him.
I made a complaint to the NSW Health Care Complaints Commission (HCCC) about Dr Matthew Doane. He sent them a long reply but asked for it not to be passed onto me. A case officer summarised it while I talked to him on the phone. Matt had apologised for the use of any language I found misleading and said that he had believed that we had a mutual understanding of the anaesthetic to be used. He misleadingly told the HCCC, ‘We discussed cancelling the operation.’ He admitted that he had used the term ‘sleep-like state’ but not the rest of what he had said.
I found Matt’s email address and contacted him, and he replied to most of my messages. He said that he hadn’t intended to deceive me about the anaesthetic. He explained some things and didn’t comment on others. He worded some parts of his emails ambiguously to avoid admitting what he had said to me at the hospital. He wouldn’t comment on whether I had been taking the risk of going under general anaesthetic and never waking up again, other than to make a vague comment about ‘lingering effects of anaesthesia and some of the risks that may be involved with these’ and having tried for a quick wake-up time. He ignored me when I suggested that he update his AHPRA listing to reflect his new job, even though he was legally required to keep it up to date.
The HCCC didn’t do much about my complaint other than passing it on to Matt and reading his response. The HCCC case officer talked to him and to me but never attempted to contact the anaesthetic nurse who could have verified what had happened. (I attempted to contact her but was unable to.) The HCCC consulted with the Medical Council of NSW as per standard procedure and then sent decision letters. The letter to me basically took Matt’s word of events and claimed that he had provided sufficient anaesthetic within the parameters of my request - whereas I felt like I had been tricked into having general anaesthetic. The HCCC case officer said that the decision letter to Matt had included some comments on the importance of clear communication.
I sent feedback and suggestions to Westmead Hospital and to the local health district organisation. However, when I mentioned that I had made a complaint to the HCCC, the hospital executive replied to say that the hospital wouldn’t comment on the matter further.
I also told various people about my experience, and wrote about it online.