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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CHECK UP
Programme 1. - Anaesthesia
RADIO 4
THURSDAY 28/07/05 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
DAVID WILKINSON
PRODUCER:
ERIKA WRIGHT
NOT CHECKED AS BROADCAST
MYERS
Hello and I'm very glad you could join us for a new series of Check Up, your opportunity to put your questions to the health experts. Today on anaesthetics, how under general anaesthetic will you lose consciousness quickly, will you have a mask over your face and how are you going to feel when you wake up? Some of us go to quite a lot of trouble to find out details of operations or medical treatments we might be having but I suspect that we're less well informed about the procedure that it's hoped will render us pain free in the process. Well now your chance to call, so ring us 08700 100 444 or you can e-mail checkup@bbc.co.uk with your questions, comments, concerns for Dr David Wilkinson, he's a consultant anaesthetist at Barts and the London Hospital.
David, I'm tempted to say of course you're the expert with anaesthetics, shouldn't we just let you get on with it, do we need to know anything?
WILKINSON
Well I think you do need to know about it, anything that's going to happen to you, whether you're awake or even more so when you're asleep, I think it's vitally important that you find out what we're going to do to you.
MYERS
Well there are plenty of people waiting to find out as it happens, so we'll go to our first caller. Mary Rogers, who's in Falmouth in Cornwall. Mary, your question please for David.
ROGERS
Thank you very much. Good afternoon Dr Wilkinson.
WILKINSON
Hello Mary.
ROGERS
I am due for - I'm on the waiting list - for an operation for osteoarthritis on both the knees and I'm concerned because I've been asked which I want and I have no idea which I want, whether to have an epidural or a general anaesthetic. Now one of my main concerns is that I am asthmatic, I've had one or two very bad attacks, but now I'm on a steroid inhaler - two doses twice a day - which is keeping it under control but I'm concerned that either the stress of hearing it all and possibly sort of being aware of it under the epidural might bring on asthma or not being able to breathe properly under general anaesthetic would be equally bad - could you please tell me?
WILKINSON
Well I think you've asked us some very good questions there Mary and I think it's a very interesting area. The basic answer is you could have it done either way, whichever way which you felt most comfortable with. I think that a patient with asthma, if it's well controlled, can have a general anaesthetic in a great deal of safety and you can also have a local anaesthetic, an epidural anaesthetic, where we put the anaesthetic close to the nerves coming out of your spine and freezing the area where they're going to operate and should you have any adverse effects on your lungs as that were going on then we could treat that as it all happened.
MYERS
Can you switch though, let's say you have an epidural and you've got this numbness in the area where you're being operated on but for some reason, I don't know, Mary you might have an asthmatic attack, you might get worried, can you then sort of pop the mask on and turn that into a general anaesthetic?
WILKINSON
Yes we can and you can - you can convert from a local anaesthetic on its own to a local anaesthetic with a little bit of sedation, which would mean you'd be sort of really asleep and just sort of dreaming lightly. Or we can give you a full general anaesthetic on top of all those things. So we can go from one to the other. I think if you've had a bit of general anaesthetic it's hard to wake you up again to have it purely under local but we can certainly go from local to - to local and sedation to a general anaesthetic.
MYERS
Mary, it sounds as though the choice is yours.
ROGERS
Thank you very much.
MYERS
Good luck with that, thanks very much.
ROGERS
Thank you doctor, thank you.
MYERS
Bye, bye. And we're go to another call - Cheltenham now, Jill Jones is waiting to talk to us, hello Jill.
JONES
Hello to you both. I'd be very interested in your comments. My dentist has never been able to achieve full local anaesthetic for any fillings or any treatment and he says that it's always more difficult to numb the lower jaws than the upper because of the nerve structure. This culminated last year when I needed to have an extraction and at nine injections, local anaesthetic injections, didn't work and I ended up as an emergency case under general anaesthetic. Now the anaesthetist at the hospital told me that a substantial majority of people do have this problem and also that if there's an infection in either of the tooth or the underlying gum no local anaesthetic will ever work. And I'm obviously just a bit surprised by that and wonder if Dr Wilkinson could comment.
WILKINSON
Jill, I think your anaesthetist is quite right - I think if there is an infection present around an area then local anaesthetic doesn't work and it's due to the way local anaesthetics try and get close to the nerves to have their action. If there's infection there they change their structure slightly so that the local effect doesn't work. I don't think that anybody can be resistant to local anaesthetic however, because everybody's nerves work in the same sort of way and all local anaesthetics work in a similar way.
JONES
Although that would seem to be the case with me and particularly, as I say, he says that a majority of people - a substantial majority of people do have this problem and particularly on the lower jaw.
WILKINSON
I think that's - I mean that's an interesting statement, certainly in my 30 years in anaesthesia I haven't seen that myself but it's obviously a point of view.
MYERS
And we shouldn't put people off from going to their dentists, I know there are lots of dental phobics out there and really it was very unfortunate to have - I think you said nine injections which didn't work, that is - I mean David is ...
JONES
[Indistinct words]
MYERS
... I mean clearly that - really that would be quite a severe extreme case.
JONES
I must be that and I would be really interested in taking it further and being sort of a test case because clearly that is what happened in my case.
MYERS
Sounds as though you've been a guinea pig already to an extent. Jill, we'll leave that call there if we may, thanks for making that point. And I'm just wondering though if local anaesthetics, I mean they should work, if they don't work and you have to have a general anaesthetic are there some people who resist a general anaesthetic who can't - or for other reasons can't have a general anaesthetic - to get that side of the coin?
WILKINSON
Yeah I think that there is nobody in the world, as far as I'm aware, who is totally resistant either to local anaesthesia or to general anaesthesia, there are always ways of rendering somebody pain free or unconscious.
MYERS
And of course that's exactly the point - pain free and unconscious - and that's what you should be able to achieve, either with a local or a general.
WILKINSON
Exactly.
MYERS
So people - people shouldn't be worried, except they may be worried then about how they're going to feel of course after the procedure.
WILKINSON
Yeah I think you're obviously if you have something done under local if you're happy having it done under local anaesthetic then you're going to feel better than if you've had sedative drugs with a general anaesthetic, I think that stands to reason.
MYERS
So that would be a good reason to perhaps opt for local, if appropriate, because, if you like, the recovery should be a little bit easier.
WILKINSON
Faster with no side effects, yes definitely.
MYERS
Okay, we'll go to another caller now. David Bucks waiting patiently, or I suppose it's David in Bucks as in Buckinghamshire is it?
DAVID
That's correct.
MYERS
Okay David, your question.
DAVID
Good afternoon. I think we're still on the subject of stress, no surprise. I too am due to come up for an operation next Wednesday to have half my colon removed. All pre-assessment is fine except the blood pressure, blood pressure normally is fine, as revealed by ambulatory 24 hour test but I've got volatile blood pressure and when I went to the hospital very recently by laying down for 20 minutes I was under the limit prescribed by the anaesthetist. I was asked to go to my local GP on the premise that it might lower there and it was slightly above the limit. Now the stress comes in, in that I know that the anaesthetist is sufficiently concerned that he would postpone the operation, by how long I don't know, and the longer the operation is postponed the more life threatening it becomes, so I feel as if I'm in a kind of catch 22 situation. Can you advise what the patient can do except to be super patient and super optimistic?
WILKINSON
Well I really recognise that problem, we often see patients who come along to either the pre-op assessments or actually into the operating theatre itself and their blood pressure goes through the roof because they are anxious, that's only natural isn't it, you're bound to be worried when you're in that situation ...
DAVID
You can't help it, it's psychological.
WILKINSON
No, exactly. Well I mean what's normal for us is very abnormal for you and I recognise that. But - and I think the essence of this is communication - you need to have your GP and your surgeon and your anaesthetist communicating, so that they all understand that this is the situation you're in. So that if you've got some blood pressure readings that are predominantly normal then - and with an ambulatory record of that, then that should be good enough for the anaesthetist to recognise that when you come in it's going to go up a bit and there are all sorts of drugs we can use just to calm that down.
DAVID
Can I comment that the anaesthetist does have in his possession - I know for a fact - the blood - 24 hour monitor test done about a month or so ago which was showing a bit of variability but certainly the mean level was a good 20 points less than the maximum he wants for the diastolic.
MYERS
David, may I just cut across, I hope I'm not being rude because the details are obviously very relevant to you but in general terms, and perhaps I could ask our guest to sort of illuminate this, I mean what is the importance of having the correct, if you like, or a safe blood pressure when you have a general anaesthetic?
WILKINSON
I think - yes, thank you Barbara - I think this is something that's poorly understood by a lot of people. And what tends to happen, if your blood pressure's very high and you go off to sleep under the anaesthetic the blood pressure can either fall like a stone or go rocketing up even higher. Under which circumstances you can either - you can either have a heart attack or a stroke. And these are obviously - if we're trying to make you better these aren't good things to happen to you. And so we're very keen on having the blood pressure as tightly controlled as possible. But despite all that we do recognise that there are some patients, like you David, who are a little more labile than others. And if you've tried certain medications and it's still a little bit labile then I think it's reasonable for you to ask your GP to talk to the surgeon, who will in turn talk to the anaesthetist or ask the GP to talk directly to the anaesthetist, which you can easily do, and try and come to some arrangement for you for the future.
DAVID
That's very helpful.
MYERS
Well thank you very much for making the call and good luck with the procedure. Could I just add into that, because I have an e-mail from Kate, who's saying that in the 1970s she went into hospital for a minor op and when she recovered she was told that the operation had been abandoned because her blood pressure dropped too low. She says that the anaesthetic in this case was halothane. In her case she hasn't had an operation since and she's frightened of what may happen if she needs an operation in the future, can she take any consolation from what you've been saying about current best practice?
WILKINSON
Yeah I think she can, I think Kate should know that halothane is very rarely used now in the UK and so should she require an operation in the future that wouldn't be the drug that would be used. And it's quite natural that blood pressure's do fall a little bit under general anaesthesia but halothane was well known to bring it down a lot lower than the modern agents that we use now. So she should be reassured.
MYERS
And I guess it's good to know that of course it is the role of the anaesthetist to be monitoring all those vital signs and that's really the skill of your job, making sure that you're getting the right balance of drugs, of gases, of oxygen and all the other things that are going on so that the patient is in good shape on the table.
WILKINSON
Absolutely, somebody told me the other day that we shouldn't call ourselves anaesthetists because nobody knows what that means, we should start calling ourselves normologists because we try and keep everybody as normal as possible. So it's a normal blood pressure, normal temperature, normal heart rate, normal everything - it's just that they're either unconscious or pain free.
MYERS
I heard that there was a move towards calling you perioperational consultants.
WILKINSON
Perioperative physicians, yes, that's a rather grand title.
MYERS
Okay, let's take another call now. And we'll go to Grantham and Dr Stuart Russell is there, hello?
RUSSELL
Yes hello. When I was involved with the Nottingham University Psychic Research Group we used to have an orthopaedic surgeon came to give a talk on hypnosis as used in anaesthesia, I wondered if - that was Dr Ian Fletcher - I wonder if as time's gone by whether this has actually progressed at all?
WILKINSON
I think that's a very, very interesting area Dr Russell and it's an area where if you're a keen hypnotist you're trying to push it forward a great deal all the time and that the problem, as I understand it, with hypnosis or other things perhaps like acupuncture is that not everybody is as susceptible as the next person to hypnosis or say acupuncture. And, for example, if you have an operating list of eight patients maybe one or maybe two of those might be susceptible to hypnosis to the extent where you could perform full surgery on them, others would be much less susceptible and would seem to go vaguely asleep but then as soon as you cut them they'd start screaming. Well you obviously can't work like that. But there are some patients, definitely, I've seen major surgery take place under hypnosis in some patients who are very susceptible to it and it works absolutely brilliantly.
MYERS
Thank you very much. That was a call to Check Up and we're talking to Dr David Wilkinson, who's a consultant anaesthetist. I'm interested that you are so open to that idea of hypnosis, it's very often the case I think that those who work in orthodox medicine don't necessarily always want to see some of the alternatives that are available but you've made a good point there.
WILKINSON
Yeah well I think anything if it works and it's not doing the patient any harm and it may do them a great deal of benefit is a very good thing to look at.
MYERS
Let's go to Devon and talk to Mike Lichfield next, hello Mike?
LICHFIELD
Hello, it's Mike Lichfield.
MYERS
Yes and I hear you're facing spinal surgery but there's a problem.
LICHFIELD
Possibly yeah, yeah.
MYERS
What's the problem?
LICHFIELD
Well my question is that this may be even more interesting by the fact that I heard Dr Wilkinson say a few minutes ago that hardly anybody would not be a candidate for either a local or general anaesthesia. I'm a candidate at the moment possibly, I'm waiting for an MRI scan for spinal surgery due to stenosis of some of the lower lumbar vertebrae in my spine which is interfering with the nerves into my legs and feet. But I've been told by the consultants at the hospital that they will not consider doing a general anaesthetic on me until I've lost a considerable amount of weight - I mean I am around 23 stone and just under six feet tall. I have to say that all of my sort of main body functions - blood pressure, blood sugar, blood cholesterol, heart and all the other stuff - have been well tested and they're okay and I understand that they are obviously very keen that I should lose a fair bit of weight would help the pressure on my spine anyway but the implication given was that it would be too dangerous to operate on me with a general anaesthesia for this sort of major surgery ...
MYERS
Now that's a key question there - yes will it be dangerous, could it be dangerous, what's wrong with being that sort of weight?
WILKINSON
It is more dangerous, there's no question about that. When I said that nobody would be refused either local or general anaesthetic I really meant - I didn't express myself very clearly obviously - I meant that nobody could be resistant to it, in terms that it wouldn't work for them. But I think there are patients who suffer from either chronic illness - if the patient's got very bad heart disease or very bad lung disease - it increases the risks of a general or a local anaesthetic quite significantly. Patients like yourself who are carrying a little extra weight and I'm glad this isn't television because you'd see how big I am as well ...
LICHFIELD
A lot of extra weight, it's very kind of you.
WILKINSON
But I - there is a higher risk in terms of all the things that we try and do are made a little more difficult by your size in terms of trying to watch the way you breathe, in the way that you'll breathe after the operation - you're at a much higher risk from getting pneumonia or a bad chest infection. It's very difficult to monitor the normal function of your body with ordinary blood pressure cuffs, it's very hard to get access to putting up ordinary intravenous drips and things like that on patients who are carrying extra weight. And for you then to mobilise after the operation you're at a higher risk from getting blood clots in your legs, having the danger of those clots going up and going into your lungs..
MYERS
You're building quite a case there for Mike to try and lose this weight but of course that's easier said than done.
WILKINSON
It's much easier said than done. And I recognise the difficulties and there is always this catch between your symptoms and your weight - you can't exercise a lot to lose weight quickly because of the problems you've got in your back and it's a catch 22.
LICHFIELD
I suppose my major concern is the fact that I am well aware that I need to lose a great deal of weight and at 61 years of age I'm going to do it now or not do it at all. I suppose I'm just concerned that I'm not going to lose a lot of weight quickly, not if I'm going to do it properly, and I'm concerned that the condition I'm in at the moment, which has put me walking with a frame at the present moment, down from with a stick a couple of weeks ago, is going to mean that by the time I am able to be operated on that the condition may have worsened to the point where it will make the operation have no effect.
MYERS
It's going to be a compromise isn't it.
WILKINSON
Yeah can I make a couple of suggestions? I think you should see a dietician certainly. And what about swimming? Can you swim? Because swimming is fantastic exercise and if you swim hard then you will lose weight very rapidly if you're also on a diet too.
LICHFIELD
And that's not going to put any pressure on my joints obviously if I'm swimming.
MYERS
Mike, thanks for your question. We'll need to move on to another call. Actually I've got an e-mail I want to slip in, if I may, very quickly from Mrs Skinner because she's got a real concern about her 15 month child - 15 month old child, who is having an MRI scan and that's going to be done under a general anaesthetic, obviously a small baby. Any concerns about that, should she be worried?
WILKINSON
Well I think any mother is anxious about a small child having an anaesthetic. Obviously the MRI scan is for a specific reason and Mrs Skinner should feel less worried by the fact that she will have her child looked after by an expert paediatric anaesthetist at that age group - so a specialist in children's anaesthesia. And there are no sort of long term sequela from that, no long term after effects, and the child will be up and bouncing very quickly.
MYERS
That's good to hear. John is picking up a similar theme in an e-mail here, he says does the number of anaesthetics a patient has had put them at a disadvantage when undergoing further surgery and can those anaesthetics sort of build up in the body?
WILKINSON
No they - I mean that's a common concern from John and no they can't. Anaesthetics are removed from the body very, very quickly and I could anaesthetise somebody every day, every morning, every night for a week and the accumulation is non-existent, when it's gone it's when you wake up and soon afterwards it's gone and there's no long term effects.
MYERS
Well that's interesting you say that and obviously you're right except that Andrew, I think, in Essex is going to talk to us next and is concerned about how you feel after the anaesthetic, which might be a slightly different point to the one you're making David but Andrew what's been your experience?
COLLEY
Yes hello. I've had two general anaesthetics in the last four years, I'm due to have another operation with a general anaesthetic in the autumn. And I have found that with the last two I've had, although I haven't particularly suffered any physical reactions such as - vomiting and things - I have over the next sort of four to six months suffered minor, but nevertheless troubling anxiety, depression, more psychological reaction to the anaesthetic, which I put down to the anaesthetic, and I just wondered if there was anything - any alternative I could ask for or anything I can do to alleviate that because I have heard other people have these same responses to a general anaesthetic.
WILKINSON
I think you're right Andrew and what you've experienced I think is a very natural thing. Any surgery, any anaesthesia is a stressful situation and whether you're stressed - you're aware of that stress at the time particularly, it comes out at some later point. Now when I say the anaesthetic wears off very quickly, it does, so that the sleepiness and everything else is gone but there is a stress there and there's the surgical stress as well, requires quite a lot of sort of clearing from your body and it's natural to think if we - if we punish you physically aren't we bound to punish you emotionally and mentally as well? So I think a lot of people feel a bit down in the dumps after ...
MYERS
Let me briefly bring in - and it will have to be quick - Susie in Edinburgh, who's also talking about side effects, perhaps not so psychological, what's your concern Susie, what have you experienced?
MAQUIRE
Well I suffer from migraine, I have done for a long time but only recently diagnosed as migraine and probably between four and six attacks a month and I'm wondering - I have an operation coming up in a couple of months, I wondering whether the general anaesthetic is going to affect that?
WILKINSON
Well I can tell you Susie it's going to be one of two things and I'm not trying to be glib - it's either going to make it a lot better or in fact it sometimes makes it worse and it's difficult to tell, there's no clear answer to that one.
MYERS
And a very last, very quick question about whether you might expect memory loss following anaesthetic - yes or no or a bit?
WILKINSON
You can, particularly elderly patients can suffer from memory loss and a little bit of confusion after anaesthetics.
MYERS
And weird dreams?
WILKINSON
After some anaesthetics, yes you can get some very spectacular dreams.
MYERS
Could be good as well as bad.
WILKINSON
It can be.
MYERS
Thank you very much indeed David Wilkinson, thank you very much for all your calls this afternoon. We'll have to stop there but if you missed any of this expert advice you can listen again to the whole programme if you go to Check Up at the 91Èȱ¬ website - bbc.co.uk follow the links. Or if you prefer to speak to someone then you can call our free and confidential help line, that's 0800 044 044. If you stick with Radio 4 in an hour Material World will be looking back into the history of chloroform, one of the earliest anaesthetics. Next week we'll be keeping you - not keeping you awake - we'll be trying to deal with your problems of sleep - that's insomnia.
ENDS
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