Anesthesiology: Vigil over Sleep

Falling Asleep by *tune4jack on deviantART

The ancient Greeks believed that the god of sleep and the god of death are brothers.  In anesthesiology, this isn't really too far from the truth.  Anesthesia is much more nuanced and complicated than simply putting a patient to sleep during surgery.  The science of anesthesiology has been honed over the decades to a delicate art, and is now one of the most regulated and safest branches of medicine.

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There are several distinct steps in anesthesiology:

1.  Pre-op: The anesthesiologist reviews the patient's medical record prior to surgery.  They will meet the patient and assess their airway (mouth and throat) as well as veins for IV access.

2.  Induction: The anesthesiologist induces sleep in the patient through one of several methods.  The most common are IV induction with propofol or inhalation induction with sevoflurane.  Once the patient is induced, the patient is typically intubated to protect his airway, paralyzed so the patient won't move during surgery, and given pain medication.  Throughout all of this, the anesthesiologist monitors the patient's vital signs closely and additional IV access may be obtained.

3.  Maintenance: The anesthesiologist maintains the patient under anesthesia usually with an inhalation agent (e.g. sevoflurane).  Vital signs are monitored for response to pain and surgical stimulus so medication can be given accordingly.  Breathing is monitored because it must be actively maintained by a machine while the patient's paralyzed.

4.  Wake-up: At the end of surgery, the anesthesiologist must reverse everything done to the patient (except the pain medication).  The patient's paralytic is reversed, anesthetic agents are turned off, and the patient slowly wakes up.  Vital signs are close monitored to assess the stage of anesthesia the patient is in, as extubating (removing the intubation tube) too early could be dangerous.

5.  Post-op: The anesthesiologist follows the patient to the post-op area and monitors for a few minutes during hand-off to the nurses, making sure the patient breathes adequately and pain is under adequate control.

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Most people go into anesthesiology because they enjoy 1.) procedures, 2.) taking care of patients in an acute setting, 3.) don't want to deal with the patient's chronic/social issues.  A select group of anesthesiologists pursue a chronic pain fellowship, turning heads on much of what likely drew them to anesthesia in the first place.

I've had the privilege of observing acute and chronic pain services in pediatric patients.  This particular acute pain service controls all PCAs (patient controlled analgesia) and epidurals in the hospital, and are the ones who wean patients off IV narcotics and transition them to oral narcotics and then wean them off altogether.

The chronic pain service was a different world entirely.  Each visit took up to 90 minutes and is conducted with a psychologist.  Pain is addressed in a multi-factorial manner - approaching it from a psychological, behavioral, and medical perspective.  A treatment plan may include CBT (cognitive behavioral therapy) to learn coping mechanisms to deal with/mentally lessen the pain, rehab exercises, and pain medication (rarely are narcotics actually given).

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Even though I will not be going into anesthesiology, the things and thought processes I learned will only make me a better overall physician.