The Very Short Introductions (VSI) series combines a small format with authoritative analysis and big ideas for hundreds of topic areas. Written by our expert authors, these books can change the way you think about the things that interest you and are the perfect introduction to subjects you previously knew nothing about. In this week’s VSI column, we give you Anaesthesia: A Very Short Introduction. Grow your knowledge with OUPblog and the VSI series!
Anaesthesia: A Very Short Introduction
By Aidan O’Donnell
If you go to certain pizza restaurants, you can watch the pizzaiolo take a lump of pizza dough, slap it around a bit, and toss it whirling into the air to shape it into a circle of perfect thickness before adding the toppings. This spectacle adds to the enjoyment of the diners, and the most accomplished pizzaiolos enter international competitions of pizza tossing prowess.
The basics are within reach of anyone: a lump of dough, a dusting of flour to stop it sticking, and enough room to permit different trajectories to be attempted. And it looks so easy and effortless that you might think anybody could do it. But you would be wrong, at least at first.
One of the hallmarks of an expert is to make what they are doing look effortless. Whether it is tossing pizza, throwing a clay pot on a wheel, or executing the perfect forehand smash, the experts make it look easy. The part that we don’t see is the hundreds of hours of practice, and the hundreds of times it has gone wrong; the shreds of dough stuck to the light bulb.
When I first started to train as an anaesthetist, one of the things which struck me was how easy it looked. My senior colleagues could maintain physiologically perfect general anaesthesia for hours, without seeming to pay any attention to the patient. My early efforts were far from successful.
Like a pilot at altitude, an expert anaesthetist knows the heading, and only makes subtle adjustments to the controls, while scanning the instruments from time to time to make sure that all is well. Vigilance includes not only awareness of the patient, the surgical team, and the other activity in the room, but also anticipation of when things might start to go wrong, and planning for unwelcome contingencies. The many non-technical skills of anaesthetists are not obvious to the lay observer.
The apparent ease of anaesthesia has led to calls from some quarters that anaesthesia can be routinely provided by practitioners with much less training. Surely anybody can do it: how hard can it be? There are jokes about anaesthesia being “99% boredom and 1% panic”; that induction of anaesthesia is accomplished by the use of the “big syringe and the little syringe”; that the ABC of Anaesthesia is “Airway, Book, Chair”; or that anaesthesia examinations include a paper in Sudoku, an activity seemingly favoured by the specialty.
But once in a while something happens which highlights the value of good anaesthetic care. In May 2009, the entertainer Michael Jackson hired Dr. Conrad Murray as his personal physician. On the 25th June 2009, just a few weeks later, Jackson died. On 7th November 2011 Murray was convicted of involuntary manslaughter. The verdict stated Murray caused Jackson’s death by overdose of the anaesthetic agent propofol.
Since then, my patients have sometimes expressed concerns about propofol. “I hope you’re not going to use that stuff that killed Michael Jackson,” they say. But propofol is one of the most commonly used anaesthetics in my hospital, and around the world.
Propofol is an extremely versatile anaesthetic. An appropriate dose causes rapid and smooth induction of general anaesthesia. Anaesthesia can be maintained using a specially programmed infusion pump to administer a controlled dose of propofol throughout the operation. If you give less than an anaesthetic dose, propofol is an effective sedative. It is suitable for a wide range of patients and is safe in children and in pregnancy. After a propofol anaesthetic, the patient wakes up rapidly and with a clear head, and in addition propofol has a noticeable anti-nausea effect.
Propofol is safe in the hands of anaesthetists for several reasons. During our training we are taught how to use it safely and use it only under supervision for some time. We study a great deal about its effects on the patient and we know its strengths and weaknesses in detail. We are required to pass rigorous examinations of our knowledge and competence. We monitor the patient closely throughout the operation. We know what to do when things go wrong, and we work in hospitals where the necessary assistance and equipment (such as oxygen, drugs and airway devices) is immediately to hand.
Unfortunately, none of this was true for Conrad Murray. He was a cardiologist by training. Propofol is so widely used that he might have seen it being used by an anaesthetist and concluded it was easy and harmless. Evidence was presented during the trial which suggested that Jackson begged Murray to provide propofol to help him sleep. Murray administered the propofol intravenously in Jackson’s bedroom, and then left him unattended with no monitoring system in place. When Murray did eventually check on Jackson, he was on the very point of death, but Murray did not have any resuscitation equipment and his attempts to rescue Jackson were clumsy and inappropriate. Professor Steven Shafer, an eminent and highly respected anaesthesia specialist called as a witness for the prosecution, listed at the trial seventeen violations of safe medical practice associated with Murray’s use of propofol.
Despite its versatility, propofol doesn’t cause sleep. If given enough, it will cause oblivion, but the cerebral activity necessary for sleep to be refreshing does not take place. Even though the person looks to be asleep from the outside, general anaesthesia is not sleep. Sleep is a highly structured, physiological process. It is necessary for life; we literally die without it. Michael Jackson was at the time of his death involved in punishing rehearsals for a stressful farewell tour. He was also using other drugs such as lorazepam, which would interfere with his natural sleep cycle. I am not surprised that he was aching for restful sleep but seemed unable to achieve it.
Michael Jackson did not die because propofol is a bad or dangerous drug, but because it was never meant to be used in this manner. Murray may have allowed Jackson’s status and wealth to push him out of his professional comfort zone (and well outside the boundaries of good medical practice) to administer propofol. He used it without appropriate training or experience, without vigilance, and without basic resuscitation equipment. And he discovered, in the hardest way possible, that the safe administration of anaesthetic drugs isn’t as easy as it looks.
Aidan O’Donnell is a consultant anaesthetist who works in New Zealand. He is a Fellow of the Royal College of Anaesthetists and a Fellow of the Australian and New Zealand College of Anaesthetists. He is the assistant editor of the current edition of the Oxford Handbook of Anaesthesia, and author of Anaesthesia: A Very Short Introduction.