tag:theconversation.com,2011:/global/topics/anaesthesia-36930/articlesAnaesthesia – The Conversation2023-03-01T03:55:01Ztag:theconversation.com,2011:article/2008952023-03-01T03:55:01Z2023-03-01T03:55:01ZWhy cough medicines containing pholcodine can be deadly even if you took them months before surgery<figure><img src="https://images.theconversation.com/files/512779/original/file-20230301-18-joknpv.jpg?ixlib=rb-1.1.0&rect=4%2C0%2C994%2C667&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/healthcare-people-medicine-concept-woman-pouring-512853772">Shutterstock</a></span></figcaption></figure><p>Cough medicines containing the active ingredient pholcodine are being withdrawn from sale due to safety concerns highlighted for years both in Australia and internationally.</p>
<p>Yesterday, Australia’s medicines regulator <a href="https://www.tga.gov.au/news/media-releases/pholcodine-cough-medicines-cancelled-tga-and-recalled-pharmacies-safety-reasons">announced</a> the immediate registration cancellation and recall of dozens of these over-the-counter cough medicines and lozenges.</p>
<p>This is because of the risk of a sudden, severe and life-threatening allergic reaction if people are also given specific muscle relaxant drugs while under a general anaesthetic.</p>
<p>That risk of anaphylaxis can remain weeks and months after taking the cough medicine.</p>
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Read more:
<a href="https://theconversation.com/still-coughing-after-covid-heres-why-it-happens-and-what-to-do-about-it-179471">Still coughing after COVID? Here's why it happens and what to do about it</a>
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<h2>What is pholcodine?</h2>
<p>Pholcodine (pronounced pho-co-dean) is an opioid-based medicine, which means it’s related to morphine and codeine. It works by binding to various opioid receptors in a part of the brain responsible for triggering the cough reflex.</p>
<p>As such, it is a common ingredient in many over-the-counter medicines used to treat a <a href="https://www.healthdirect.gov.au/cough">dry cough</a>. These include cough syrups and lozenges. Every product that contains pholcodine will list it prominently on the bottle or cardboard packaging. </p>
<p>Common brands that contain this ingredient include Benadryl, Bisolvon, Codral, Difflam, Difflam Plus and Duro-Tuss.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/sore-throats-suck-do-throat-lozenges-help-at-all-184454">Sore throats suck. Do throat lozenges help at all?</a>
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<h2>Why the recall?</h2>
<p>The most common side effects of pholcodine are dizziness, nausea and sedation. But the Therapeutic Goods Administration (TGA) has recalled products containing it, as pholcodine can trigger anaphylaxis around the time of surgery.</p>
<p>The issue arises when pholcodine medicines are combined with types of muscle relaxants given during surgery known as <a href="https://www.cec.health.nsw.gov.au/keep-patients-safe/medication-safety/high-risk-medicines/neuromuscular-blocking-agents">neuromuscular blocking agents</a>.</p>
<p>This type of anaphylaxis can occur in people who have had a muscle relaxant before and been previously fine, or in people who receive a muscle relaxant drug for the first time.</p>
<p>Being <a href="https://www.sciencedirect.com/science/article/pii/S0007091220310072?via%3Dihub">obese</a> also places people at higher risk of this type of anaphylaxis.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/512777/original/file-20230301-3384-mk2uiz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person under anesthesia during surgery, gas mask over face" src="https://images.theconversation.com/files/512777/original/file-20230301-3384-mk2uiz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/512777/original/file-20230301-3384-mk2uiz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/512777/original/file-20230301-3384-mk2uiz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/512777/original/file-20230301-3384-mk2uiz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/512777/original/file-20230301-3384-mk2uiz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/512777/original/file-20230301-3384-mk2uiz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/512777/original/file-20230301-3384-mk2uiz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Muscle relaxants given during surgery plus pholcodine can be a lethal mix.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/necessary-procedure-close-young-patient-lying-1220709154">Shutterstock</a></span>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/cough-syrup-can-harm-children-experts-warn-of-contamination-risks-199795">Cough syrup can harm children: experts warn of contamination risks</a>
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<h2>We’ve known about the risk for years</h2>
<p>We have actually known about the risks of pholcodine and muscle relaxants for some time, including in <a href="https://onlinelibrary.wiley.com/doi/10.1111/j.1399-6576.2004.00591.x">Scandinavian studies</a> in 2005.</p>
<p>In fact, it was because of these studies that pholcodine was withdrawn from the market in Norway <a href="https://onlinelibrary.wiley.com/doi/10.1111/j.1398-9995.2010.02518.x">in 2007</a>.</p>
<p>The European Medicines Agency recommended <a href="https://www.ema.europa.eu/en/news/ema-recommends-withdrawal-pholcodine-medicines-eu-market">the withdrawal of pholcodine</a> in Europe in December 2022.</p>
<p>In Australia, the <a href="https://www.psnetwork.org/ban-pholcodine/">PatientSafe Network</a> has been calling for its ban since at least 2017. </p>
<p>Over the past 12 months, there were nine reported cases of serious adverse effects to pholcodine reported to the TGA, including three deaths. The most recent case was in January this year. In three of the nine, pholcodine was the only suspected medicine involved. </p>
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<a href="https://images.theconversation.com/files/512764/original/file-20230228-2348-2al141.jpg?ixlib=rb-1.1.0&rect=72%2C591%2C3959%2C2323&q=45&auto=format&w=1000&fit=clip"><img alt="Some common products affected by the recall" src="https://images.theconversation.com/files/512764/original/file-20230228-2348-2al141.jpg?ixlib=rb-1.1.0&rect=72%2C591%2C3959%2C2323&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/512764/original/file-20230228-2348-2al141.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/512764/original/file-20230228-2348-2al141.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/512764/original/file-20230228-2348-2al141.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/512764/original/file-20230228-2348-2al141.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/512764/original/file-20230228-2348-2al141.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/512764/original/file-20230228-2348-2al141.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">These common cough syrups and lozenges are among products being recalled.</span>
<span class="attribution"><span class="license">Author provided</span></span>
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<h2>Why now?</h2>
<p>The TGA’s decision may come from a recent (but not yet peer reviewed) French <a href="https://www.medrxiv.org/content/10.1101/2022.12.12.22283353v1.full">study</a>. This found that when patients had taken pholcodine at any time in the 12 months before surgery that used a muscle relaxant, they were at much higher risk of anaphylaxis.</p>
<p>The French research is consistent with an earlier <a href="https://www.sciencedirect.com/science/article/pii/S0007091220310072?via%3Dihub">Western Australian study</a> which found anaphylaxis is 14 times more likely to occur when the two types of drugs are combined.</p>
<p>This is because pholcodine can linger in the body for long periods. After you swallow the medicine, the drug reaches its highest concentration in the blood stream <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1386567/">one to two hours later</a>. But both the drug and its metabolites can still be detected in the body <a href="https://www.medsafe.govt.nz/committees/marc/reports/180-3.2.1-Pholcodine.pdf">up to seven weeks later</a>.</p>
<h2>I have some at home. What now?</h2>
<p>As pholcodine can linger in the body, the TGA has warned that if you have taken a medicine containing pholcodine in the past 12 months you need to tell your doctor before you have surgery.</p>
<p>If you are taking one of these medicines you should stop immediately, even if you don’t think you’re going to have a medical procedure soon. </p>
<p>Take it to your local pharmacy for disposal. At that time, the pharmacist will be able to recommend a <a href="https://theconversation.com/health-check-do-cough-medicines-work-62425">different medicine</a> for your cough.</p>
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<strong>
Read more:
<a href="https://theconversation.com/health-check-do-cough-medicines-work-62425">Health Check: do cough medicines work?</a>
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<img src="https://counter.theconversation.com/content/200895/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Associate Professor Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is a Fellow of the Royal Australian Chemical Institute, a member of the Australasian Pharmaceutical Science Association, and a member of the Australian Institute of Company Directors. Nial is the chief scientific officer of Vairea Skincare LLC, a director of SetDose Pty Ltd a medical device company, and a Standards Australia panel member for sunscreen agents.</span></em></p><p class="fine-print"><em><span>Associate Professor Tina Hinton has previously received funding from the Schizophrenia Research Institute (formerly Neuroscience Institute of Schizophrenia and Allied Disorders). She is currently a Board member of the Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists.</span></em></p>The risk of a severe allergic reaction when pholcodine is combined with common medicines used in anaesthesia has lead to their recall in Australia.Nial Wheate, Associate Professor of the Sydney Pharmacy School, University of SydneyTina Hinton, Associate Professor of Pharmacology, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1876402022-08-03T06:59:03Z2022-08-03T06:59:03ZHow do epidurals work? And why is there a global shortage of them?<figure><img src="https://images.theconversation.com/files/477070/original/file-20220802-17-orrm1p.jpg?ixlib=rb-1.1.0&rect=25%2C68%2C5716%2C3716&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mid-adult-female-nurse-comforting-tensed-228783766">Shutterstock</a></span></figcaption></figure><p>More than <a href="https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies/contents/labour-and-birth/analgesia">40%</a> of people in Australia who access pain relief during labour use epidurals. That amounts to around <a href="https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies/data">92,000 epidurals</a> a year. They’re also used for pain relief outside obstetrics. </p>
<p>However, Australia is feeling the effects of a global supply shortage of <a href="https://www.anzca.edu.au/safety-advocacy/safety-alerts/management-of-potential-supply-disruption-to-epidu">particular brands of epidural kits</a>. While this shortage was expected to be resolved at the end of last month, a spokesperson for the Therapeutic Goods Administration (TGA) told The Conversation it would continue beyond July.</p>
<p>Health authorities are <a href="https://www.smh.com.au/national/use-of-epidural-kits-limited-as-global-shortage-hits-australian-hospitals-20220721-p5b3i3.html?utm_medium=Social&utm_source=Twitter#Echobox=1658646526-1">reportedly</a> distributing stock to affected hospitals and working to secure additional kits, while the TGA is investigating how it can “allow [the] supply of alternative products to meet market demand”. </p>
<p>In the meantime, <a href="https://www.smh.com.au/national/use-of-epidural-kits-limited-as-global-shortage-hits-australian-hospitals-20220721-p5b3i3.html?utm_medium=Social&utm_source=Twitter#Echobox=1658646526-1">Victorian and NSW health authorities recommend</a> conserving epidural kits for obstetric patients.</p>
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<h2>Remind me, what’s an epidural?</h2>
<p>An epidural for people in labour is an anaesthetic procedure used to deliver nerve-blocking drugs, via a tiny plastic tube, into the “epidural space” in the back, through which spinal nerves travel. They’re <a href="https://www.anzca.edu.au/patient-information/anaesthesia-information-for-patients-and-carers/pain-relief-and-having-a-baby">performed by anaesthetists</a>, who are specialist doctors. </p>
<p>The doctor first identifies the epidural space using a needle and a specially designed syringe, then passes a small tube into the space. </p>
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<a href="https://images.theconversation.com/files/477057/original/file-20220802-18-9oy7yj.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Graphic of the epidural procedure and anatomy involved" src="https://images.theconversation.com/files/477057/original/file-20220802-18-9oy7yj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/477057/original/file-20220802-18-9oy7yj.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=299&fit=crop&dpr=1 600w, https://images.theconversation.com/files/477057/original/file-20220802-18-9oy7yj.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=299&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/477057/original/file-20220802-18-9oy7yj.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=299&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/477057/original/file-20220802-18-9oy7yj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=376&fit=crop&dpr=1 754w, https://images.theconversation.com/files/477057/original/file-20220802-18-9oy7yj.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=376&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/477057/original/file-20220802-18-9oy7yj.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=376&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Nerve-blocking drugs are delivered into the epidural space in the back.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/epidural-spinal-block-anaesthesia-pinched-relieve-1769472845">Shutterstock</a></span>
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<p>Medications – usually local anaesthetics and morphine-like drugs – are administered down the tube. Pain relief is usually achieved <a href="https://theconversation.com/explainer-what-is-an-epidural-for-labour-64870">within about 20 minutes</a>. </p>
<h2>Why is there a shortage of epidurals?</h2>
<p>In <a href="https://www.supplychain.nhs.uk/icn/supply-issues-smiths-medical-international-ltd-epidural-kits-multiple-products/">April</a>, one of the leading international manufacturers of epidurals <a href="https://rcoa.ac.uk/news/temporary-disruption-supply-smiths-medical-epidural-combined-epiduralspinal-products">announced a temporary disruption</a> to its supply.</p>
<p>This specific supply chain issue relates to the lack of supply of blue dye some manufacturers use to colour the special low-friction plunger-style epidural syringe. This syringe is important because anaesthetists use it to identify the epidural space in the patient’s back.</p>
<p>The syringe is usually filled with saline and connected to the hollow epidural needle, which is then slowly advanced into the back. </p>
<p>The anaesthetist places constant pressure on the syringe and when the epidural space is located, there is a “loss of resistance”. The saline passes easily into it, opening up this space so the epidural catheter can smoothly be passed into it. </p>
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<a href="https://images.theconversation.com/files/477270/original/file-20220803-23-359kso.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Screenshot of epidural kits with blue syringe" src="https://images.theconversation.com/files/477270/original/file-20220803-23-359kso.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/477270/original/file-20220803-23-359kso.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=288&fit=crop&dpr=1 600w, https://images.theconversation.com/files/477270/original/file-20220803-23-359kso.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=288&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/477270/original/file-20220803-23-359kso.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=288&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/477270/original/file-20220803-23-359kso.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=362&fit=crop&dpr=1 754w, https://images.theconversation.com/files/477270/original/file-20220803-23-359kso.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=362&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/477270/original/file-20220803-23-359kso.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=362&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Dye to colour the blue syringes is in low supply.</span>
<span class="attribution"><a class="source" href="https://www.smiths-medical.com/en-au/products/pain-management/epidural-anesthesia">Screenshot from smiths-medical.com</a></span>
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<p>The familiar blue colour of the low-friction syringe distinguishes it from other syringes, which are clear and used for injecting medications. The colouring of the syringe ensures ease of identification and safety so the correct syringe is used for the procedure.</p>
<p>This unpredictable and sudden loss of a brand of epidural kits has put global pressure on other manufacturers of epidural kits, and their component parts, resulting in a worldwide shortage. </p>
<h2>How epidurals have changed</h2>
<p>Epidurals have been commonly used for pain relief in childbirth for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3417963/">more than 40 years</a> although the history of epidurals dates back <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3417963/">over 100 years</a>.</p>
<p>When first introduced, epidurals were known as “heavy epidurals”, where high-dose anaesthetic drugs blocked the large muscle nerves as well as the smaller pain, temperature and balance nerves. Blocking the nerves to the muscles meant patients were unable to move about their birthing bed, making it difficult to push, and making them feel heavy.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-an-epidural-for-labour-64870">Explainer: what is an epidural for labour?</a>
</strong>
</em>
</p>
<hr>
<p>Contemporary epidurals now use low doses of anaesthetic that only block pain, temperature and balance nerves. This type of epidural provides excellent pain relief while also enabling movement in bed because the muscles in the legs are not effected. </p>
<p>Modern epidurals can be “topped up” with high-dose anaesthetics to make an epidural suitable to provide anaesthesia for caesarean birth. </p>
<p>However, most <a href="https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies/contents/labour-and-birth/anaesthesia">caesarean births</a> (69%) use spinal anaesthesia. These use different equipment to epidurals, so caesareans would not be impacted by epidural supply issues.</p>
<figure class="align-center ">
<img alt="Woman in labour breathes heavily" src="https://images.theconversation.com/files/477367/original/file-20220803-26-pv5yw8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/477367/original/file-20220803-26-pv5yw8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/477367/original/file-20220803-26-pv5yw8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/477367/original/file-20220803-26-pv5yw8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/477367/original/file-20220803-26-pv5yw8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/477367/original/file-20220803-26-pv5yw8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/477367/original/file-20220803-26-pv5yw8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Modern epidurals enable movement in the bed.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/darkhaired-woman-giving-birth-home-pierced-2145598585">Shutterstock</a></span>
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<p>Epidurals were once used for pain relief for patients undergoing a wide range of surgeries outside obstetrics. While they’re <a href="https://www.nysora.com/topics/regional-anesthesia-for-specific-surgical-procedures/abdomen/epidural-anesthesia-analgesia/">still used</a> to help very unwell patients – for example, after major high-risk cancer surgeries and trauma surgeries – they’re less commonly used and provide fewer benefits for <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(02)08266-1/fulltext">less ill patients</a>.</p>
<p>To manage pain, many of these patients can have a spinal morphine injection, or opioid drugs such as morphine administered via a drip. </p>
<h2>Preparing for global supply shortages</h2>
<p>In addition to nitrous oxide, and morphine injections, there are some other drug alternatives to epidurals for pain relief in labour. These include the morphine-like drugs, administered via a drip, providing person-controlled analgesia (PCA) or a very low-dose spinal anaesthetic. </p>
<p>However, global supply chain problems will remain with us for many years because of pandemics, wars and natural disasters, and we need to be prepared for them. This means having alert systems to identify sooner potential supply chain issues. Part of this process is to observe what is happening in other countries. </p>
<p>The sooner we know of problems, such as epidural kit supply issues, the sooner we can start to rationalise their distribution. In doing so, such shortages can be anticipated and mitigated. We need to lessen the impact of the supply reduction on those who need it most and ensure people don’t face the potential trauma of uncontrolled labour pain.</p>
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Read more:
<a href="https://theconversation.com/three-simple-things-australia-should-do-to-secure-access-to-treatments-vaccines-tests-and-devices-during-the-coronavirus-crisis-136052">Three simple things Australia should do to secure access to treatments, vaccines, tests and devices during the coronavirus crisis</a>
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<p><em>Correction: this article originally said more than 40% of people who give birth in Australia use epidurals for pain relief during labour. This has now been updated.</em></p><img src="https://counter.theconversation.com/content/187640/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alicia Dennis receives research funding from the Australian and New Zealand College of Anaesthetists (ANZCA) and the University of Melbourne. She is a member of Scientific Affairs Committee World Federation of Societies of Anaesthesiologists, the Australian Society of Anaesthetists, the Australian Institute of Company Directors, the Australian Medical Association, Women on Boards, and Society of Anesthesiology and Perinatology. Alicia Dennis previously received funding from the National Health and Medical Research Council (NHMRC) Australia
Alicia Dennis is a full time staff specialist and Director of Anaesthesia Research at the Royal Women's Hospital, Parkville,
Australia. In July 2022 she participated in a Department of Health (Victoria) Epidural Catheter Supply Chain Issue meeting as a clinical subject matter expert. </span></em></p>Epidurals deliver nerve-blocking drugs into the back for pain relief during labour and after surgeries. Epidural kits are currently in short supply, with their use prioritised for obstetric patients.Alicia Dennis, Professor MBBS, PhD, MPH, PGDipEcho, FANZCA, GAICD, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1850812022-06-24T12:02:22Z2022-06-24T12:02:22ZFive billion people can’t afford surgery – a team of innovators could soon change this<figure><img src="https://images.theconversation.com/files/470537/original/file-20220623-51718-lguur2.jpg?ixlib=rb-1.1.0&rect=33%2C42%2C5573%2C3690&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Gasless laparoscopic surgery performed by Dr Biju Islary using the RAIS system.</span> <span class="attribution"><span class="source">Dr. Hampher Kynjing, Nazareth Hospital, Shillong</span>, <span class="license">Author provided</span></span></figcaption></figure><p>Have you or a loved one ever needed surgery? Imagine what your life would be like if you couldn’t have it. Billions of people around the world lack access to surgery because equipment and general anaesthesia are too expensive or unsuitable in their region. </p>
<p>When we think about technological progress people tend to picture faster, shinier, more hi-tech upgrades of what we already have. But sometimes developers can have more impact by remodelling technology with cheaper and simpler versions. </p>
<p>Our group at the University of Leeds is developing surgical technology for low-to-middle income countries and our first project was a simplified surgical tool for performing laparoscopic – or keyhole – surgery in low-resource settings where it was not possible before.</p>
<p>Surgical technology has never been more advanced. The NHS is <a href="https://www.sciencedirect.com/science/article/pii/S0168851022000562">adopting robotic surgical systems</a>, which give surgeons new levels of precision and skill to perform complex procedures for <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2758472">prostate, gynaecology and bowel surgery</a>. </p>
<p>But while these advances are impressive, they highlight a stark inequality; an estimated 5 billion people (more than two-thirds of the global population) <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60160-X/fulltext">cannot afford surgery</a>. And yet, surgery is the primary treatment for one-third of diseases. Of the 313 million procedures undertaken worldwide each year, only 6% are performed in the poorest countries, where more than one-third of the world’s population lives. </p>
<h2>Why surgery is so hard to access</h2>
<p>A <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(14)70349-3/fulltext">shortage of trained surgeons</a>, healthcare costs and cultural barriers (many people turn to traditional healers first) prevent access, but all too often there is not enough <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61127-1/fulltext">appropriate surgical equipment</a> available. By that we mean technology that fits the resources and services available in the <a href="https://gh.bmj.com/content/4/5/e001808">local healthcare setting</a> and does so at a cost affordable to local patients. </p>
<p>The shortage of technology designed for low-resource regions is because biotech firms focus on the major commercial markets in the EU, US and China and are reluctant to undercut more expensive, profitable technologies. </p>
<p>The solution is not as simple as providing low-income countries with the same surgical technology used in high-income countries. <a href="https://gh.bmj.com/node/135437.full">Well-meaning donations</a> of surgical equipment are often unused because they are too expensive to maintain. Communities struggle to source items such as air filters, cutting blades and CO₂ gas to make equipment work. </p>
<p>Research reveals 40-70% of medical devices in low-to-middle income countries are <a href="https://link.springer.com/article/10.1186/s12992-017-0280-2">broken, unused or unfit for purpose</a>.</p>
<h2>What we did</h2>
<p>We set out trying to develop new surgical equipment tailored to low and middle income countries, using “frugal innovation” as our guiding principle, meaning we were aiming <a href="https://academic.oup.com/bjs/article/106/2/e34/6120763?login=false">to do more with less</a>“. <a href="https://journals.lww.com/ijsgh/Fulltext/2021/01010/Designing_devices_for_global_surgery__evaluation.7.aspx?context=LatestArticles">We also</a> involved clinical staff throughout the process. </p>
<p><a href="https://ieeexplore.ieee.org/document/9780179">Our project</a> helped surgeons practice vital keyhole surgery in remote areas of rural India. In laparoscopic surgery, the patient’s abdomen is inflated with CO₂ gas and the surgeon operates using long instruments which go through small incisions into the space created. The technique, <a href="https://pubmed.ncbi.nlm.nih.gov/11019611/">pioneered in 1901</a> in Germany, revolutionised modern surgery, reducing their risk of infections and dramatically lowering the recovery time for patients.</p>
<p>Unfortunately, it requires general anaesthesia, and a reliable CO₂ supply, both of which are too expensive in low-resource regions. General anaesthesia must be administered by an anaesthetist. An alternative technique, <a href="https://link.springer.com/article/10.1007/s00464-015-4433-1">gasless laparoscopy</a>, uses a mechanical retractor to lift the abdomen and create space. This method doesn’t require CO₂ and allows the use of readily available spinal anaesthesia instead. </p>
<p>Spinal anaesthesia can be carried out by the operating surgeon, removing the need for a specialist anaesthetist. It means that patients in poorer countries can be given essential surgical treatments such as appendectomy, gall bladder removal, gynecological procedures. It also enables patients to return to work quickly, which is important because the longer patients are off work sick, the deeper they fall below the poverty line. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/469869/original/file-20220620-26-zat5h3.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/469869/original/file-20220620-26-zat5h3.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=337&fit=crop&dpr=1 600w, https://images.theconversation.com/files/469869/original/file-20220620-26-zat5h3.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=337&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/469869/original/file-20220620-26-zat5h3.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=337&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/469869/original/file-20220620-26-zat5h3.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=423&fit=crop&dpr=1 754w, https://images.theconversation.com/files/469869/original/file-20220620-26-zat5h3.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=423&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/469869/original/file-20220620-26-zat5h3.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=423&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Gasless laparoscopic surgery: the abdomenal wall is lifted by a ‘retractor’ to create space for instruments and a camera.</span>
</figcaption>
</figure>
<p>There is <a href="https://www.sciencedirect.com/science/article/pii/S1072751520320986">huge potential for gasless surgery</a> but uptake has been limited because the retractors are bulky, hard to use and maintain and are expensive.</p>
<p>Our designers teamed with surgeons to create a modern retraction system. We worked together to understand their needs and develop better retractors through repeated testing. The result is <a href="https://ieeexplore.ieee.org/document/9780179">"RAIS” (Retractor for Abdominal Insufflation-less Surgery)</a> which is being produced by our commercial partner (<a href="https://www.xlo.in/">Ortho Life Systems</a>). It costs $980 (£802), about one-third of the price of the older retractors. </p>
<p>The response from our surgical partners has been encouraging. Dr Biju Islary, surgeon and expert in gasless laparoscopy at Crofts Memorial Christian Hospital, India, said: “I have been involved from the start … this is a very good device to use.”</p>
<p>It is being used in ten medical centres in rural Indian states and we are working to expand this to new areas in India and around the world. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/470538/original/file-20220623-60671-rxz6ee.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/470538/original/file-20220623-60671-rxz6ee.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=187&fit=crop&dpr=1 600w, https://images.theconversation.com/files/470538/original/file-20220623-60671-rxz6ee.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=187&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/470538/original/file-20220623-60671-rxz6ee.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=187&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/470538/original/file-20220623-60671-rxz6ee.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=235&fit=crop&dpr=1 754w, https://images.theconversation.com/files/470538/original/file-20220623-60671-rxz6ee.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=235&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/470538/original/file-20220623-60671-rxz6ee.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=235&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The RAIS system has been used in clinical centres across India. Pictured left to right; Dr Biju Islary (Crofts Memorial Christian Hospital, Assam), Prof. Anurag Mishra (Maulana Azad Medical College, New Delhi), Dr Jesudian Gnanaraj (SEESHA, Coimbatore), Dr Gordon Rangad (Nazareth Hospital, Shillong)</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>A problem close to home</h2>
<p>Even <a href="https://www.sciencedirect.com/science/article/pii/S2214999616307755">higher-income countries</a> struggle with <a href="https://research.one.surgery/beyond-technology-review-of-systemic-innovation-stories-in-global-surgery/">unequal access to surgical care</a>. Postcode lotteries create disparity in availability of healthcare, in places such as the US or UK. </p>
<p>The UK’s <a href="https://www.leedsth.nhs.uk/about-us/sustainability/news/2021/11/15/leeds-teaching-hospitals-nhs-trust-crowned-winners-of-the-green-surgery-challenge-2021">Green Surgery Challenge</a> has recently highlighted how frugal approaches could save the NHS money. For example, reusable instruments and surgical kit together with washable gowns and drapes, rather than single-use disposable items, are more environmentally friendly and cost effective.</p>
<p>Our aim is to form an international collaboration. We held the first <a href="https://surgicalinnovations.org/wpp/">International Congress for Innovation in Global Surgery</a> in April 2022. There is a lot of scope for improvement in access to gasless surgery and we will work together to improve the other technology involved, including camera systems and monitoring devices. </p>
<p>Technology innovation has an <a href="https://pubmed.ncbi.nlm.nih.gov/27890315/">important role to play in surgery</a>. People get excited about the release of a new video game or smartphone – but what could be more incredible than saving a life? Few products have as great an impact on people’s lives as accessible medical equipment. It is time for technology developers to think outside the box and create surgical products for low and medium-income countries – a market of billions.</p><img src="https://counter.theconversation.com/content/185081/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Pete Culmer receives funding from the UK Engineering and Science Research Council (EPSRC) and the UK National Institute of Health Research (NIHR). He is affiliated with the Institute of Mechanical Engineering (IMechE) Biomedical Engineering Division.
The authors would like to acknowledge the research team whose dedication, passion and expertise have made this work possible, with thanks to everyone including: Association of Rural Surgeons of India and International Federation of Rural Surgeons, Anurag Mishra, Lovenish Bains and team at the Maulana Azad Medical College, New Delhi, India, Tim Beacon, Medical Aid International, Sundeep Singh Sawhney, Tamandeep Singh Kochhar and team at Ortho Life Systems, New Delhi, India; Richard Hall and Philippa Bridges at Pd-m International Ltd, Thirsk, UK; Millie Marriott Webb, Cheryl Harris and David Jayne at the University of Leeds, UK</span></em></p><p class="fine-print"><em><span>Noel Aruparayil worked as a clinical research fellow funded by NIHR Global Health. He is on the Global Surgery Foundation committee for the Royal College of Surgeons of Edinburgh and sits on the advisory board for GASOC (Global Anaesthesia, Surgery and Obstetric Collaboration). </span></em></p><p class="fine-print"><em><span>Jesudian Gnanaraj does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A team of doctors and academics worked together on back-to-basics surgical equipment that is already changing lives.Pete Culmer, Associate Professor in Surgical Technologies, University of LeedsJesudian Gnanaraj, Professor of electronics and instrumentation engineering, Karunya Institute of Technology and SciencesNoel Aruparayil, Clinical research fellow in global surgery, University of LeedsLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1654982021-08-04T13:53:55Z2021-08-04T13:53:55ZConsciousness: how the brain chemical ‘dopamine’ plays a key role – new research<figure><img src="https://images.theconversation.com/files/414565/original/file-20210804-23-6uxhp1.jpg?ixlib=rb-1.1.0&rect=286%2C0%2C2944%2C2475&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">We know very little about the human brain.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/dopamine-molecule-formula-3d-diagram-illustration-1294151767">Orla/Shutterstock</a></span></figcaption></figure><p>Consciousness is arguably the most important scientific topic there is. Without consciousness, there would after all be no science. But while we all know what it is like to be conscious – meaning that we have personal awareness and respond to the world around us – it has turned out to be near impossible to explain exactly how it arises from the hardware of the brain. This is dubbed the “hard” problem of consciousness.</p>
<p>Solving the hard problem is a matter of great scientific curiosity. But so far, we haven’t even solved the “easy” problems of explaining which brain systems give rise to conscious experiences in general – in humans or other animals. This is of huge clinical importance. Disorders of consciousness are a common consequence of severe brain injury and include comas and vegetative states. And we all experience temporary loss of awareness when under anaesthesia during an operation. </p>
<p>In a <a href="https://www.pnas.org/content/pnas/118/30/e2026289118.full.pdf">study published</a> in the Proceedings of the National Academies of Science, we have now shown that conscious brain activity seems to be linked to the brain’s “<a href="https://theconversation.com/explainer-what-is-dopamine-and-is-it-to-blame-for-our-addictions-51268">pleasure chemical</a>”, dopamine. </p>
<p>The fact that the neural mechanisms that underpin consciousness disorders are difficult to characterise makes these conditions hard to diagnose and treat. Brain-imaging has established that a network of interconnected brain regions, known as the default mode network, <a href="https://www.jneurosci.org/content/jneuro/35/46/15254.full.pdf">is involved</a> in self-awareness. This network has also been shown to be impaired in anaesthesia and after brain damage that causes disorders of consciousness. Importantly, it seems to be crucial to conscious experience.</p>
<p>Some patients, however, may seem to be unconscious when they in fact are not. In a landmark study in 2006, a team of researchers showed that a 23-year old woman, who suffered severe brain trauma and was thought to be in a vegetative state following a traffic accident, <a href="https://science.sciencemag.org/content/313/5792/1402?hwshib2=authn%3A1627638528%3A20210729%253A06b71cd0-ab1f-40c0-9b86-b84e4e545ab0%3A0%3A0%3A0%3Ag%2B6AEilw1d5n2EaRFnoEsw%3D%3D">had signs of awareness</a>. The patient was asked to imagine playing tennis <a href="https://global.oup.com/academic/product/sex-lies-and-brain-scans-9780198752899?cc=gb&lang=en&">during a brain scan (fMRI)</a>) and the scientists saw that regions of the brain involved in motor processes activated in response. </p>
<p>Similarly, when she was asked to imagine walking through the rooms of her home, regions of the brain involved in spatial navigation, such as the <a href="https://www.neuroscientificallychallenged.com/blog/know-your-brain-posterior-parietal-cortex">posterior parietal cortex</a>, became active. The pattern of activation that she showed was similar to that of healthy people, and she was deemed to have awareness even though that wasn’t noticeable in classical clinical assessment (not involving brain scans).</p>
<p>Other research has found similar effects in other vegetative state patients. This year, a group of scientists, writing in <a href="https://www.dailymail.co.uk/news/article-9845353/Thousands-patients-thought-vegetative-state-really-awake-experts-warn.html">the journal Brain</a>, warned that one in five patients in vegetative states may in fact be conscious enough to follow commands <a href="https://academic.oup.com/brain/article-abstract/144/6/1655/6199232?redirectedFrom=fulltext">during brain scans</a> – though there is no <a href="https://pubmed.ncbi.nlm.nih.gov/20130250/">consensus on this</a>. </p>
<h2>The brain chemical involved in consciousness</h2>
<p>So how do we help these people? The brain is more than just a congregation of different areas. Brain cells also rely on a number of chemicals to communicate with other cells – enabling a number of brain functions. Before our study, there was already some evidence that dopamine, well known for its role in reward, also plays a role in disorders of consciousness. </p>
<figure class="align-center ">
<img alt="Dopamine molecule formula and 3D diagram." src="https://images.theconversation.com/files/414564/original/file-20210804-17-1lmipkk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/414564/original/file-20210804-17-1lmipkk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/414564/original/file-20210804-17-1lmipkk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/414564/original/file-20210804-17-1lmipkk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/414564/original/file-20210804-17-1lmipkk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/414564/original/file-20210804-17-1lmipkk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/414564/original/file-20210804-17-1lmipkk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Dopamine, the brain’s pleasure chemical.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/dopamine-molecule-formula-3d-diagram-illustration-1294151767">Andrea Danti/shutterstock</a></span>
</figcaption>
</figure>
<p>For example, <a href="https://pubmed.ncbi.nlm.nih.gov/31505542/">one study</a> showed that dopamine release in the brain is impaired in minimally conscious patients. Moreover, a number of small-scale studies have shown that patients’ consciousness can improve by giving them drugs that act through dopamine. </p>
<p>The dopamine source in the brain is called the <a href="https://www.neuroscientificallychallenged.com/blog/know-your-brain-ventral-tegmental-area">ventral tegmental area</a> (VTA). It is from this region that <a href="https://www.frontiersin.org/articles/10.3389/fncir.2017.00108/full">dopamine is released</a> to most areas in the cortex. In our recent study, we showed that the function of this source of the brain’s dopamine is impaired in patients with disorders of consciousness and also in healthy people after the administration of an anaesthetic. </p>
<p>In healthy people, we found that VTA function was restored after withdrawal of sedation. And people with reduced consciousness who improved over time also regained some of their VTA function. In addition, the dysfunction in dopamine was linked with a dysfunction in the default mode network, which we already know is key in consciousness. This suggests that dopamine may really have a central role in maintaining our consciousness. </p>
<p>The study, carried out in the Division of Anaesthesia at the University of Cambridge, also shows that the use of current and future drugs, which act on dopamine, should help improve our understanding of anaesthesia. Surprisingly, although anaesthesia with ether was first used in surgery at <a href="https://rcoa.ac.uk/about-college/heritage/history-anaesthe,sia">Massachusetts General Hospital in 1846</a>, the specific processes as to how general anaesthetics act at multiple sites to produce anaesthetic action remain a mystery. </p>
<p>But the most exciting aspect of this research is ultimately that it gives hope for <a href="https://www.pnas.org/content/118/31/e2111268118">better treatments</a> of consciousness disorders, using drugs that act on dopamine.</p><img src="https://counter.theconversation.com/content/165498/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Barbara Jacquelyn Sahakian receives funding from the Wellcome Trust, the Lundbeck Foundation and the Leverhulme Foundation. Her research is conducted within the NIHR Cambridge Biomedical Research Centre (Mental Health and Neurodegeneration Themes) and the NIHR MedTech and Invitro Diagnostic Co-operative (MIC).</span></em></p><p class="fine-print"><em><span>Christelle Langley receives funding from the Wellcome Trust. </span></em></p><p class="fine-print"><em><span>Emmanuel A Stamatakis receives funding from the Canadian Institute for Advanced Research and the Stephen Erskine Fellowship, Queens’ College, University of Cambridge. </span></em></p><p class="fine-print"><em><span>Lennart Spindler receives funding from The Cambridge International Trust, and the Cambridge European Scholarship. </span></em></p>Drugs which act through the brain chemical dopamine may one day help restore consciousness in people who have lost it.Barbara Jacquelyn Sahakian, Professor of Clinical Neuropsychology, University of CambridgeChristelle Langley, Postdoctoral Research Associate, Cognitive Neuroscience, University of CambridgeEmmanuel A Stamatakis, Lead, Cognition and Consciousness Imaging Group, Division of Anaesthesia, University of CambridgeLennart Spindler, PhD Candidate of Neuroscience, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1596532021-04-27T09:18:57Z2021-04-27T09:18:57ZEnd-of-life care: people should have the option of general anaesthesia as they die<figure><img src="https://images.theconversation.com/files/397119/original/file-20210426-17-suabjh.jpg?ixlib=rb-1.1.0&rect=0%2C19%2C6419%2C4295&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/man-holding-hand-giving-support-comfort-1576363936">KieferPix/Shutterstock</a></span></figcaption></figure><p>Dying patients who are in pain are <a href="https://pubmed.ncbi.nlm.nih.gov/12732169/">usually given an analgesic</a>, such as morphine, to ease their final hours and days. And if an analgesic isn’t enough, they <a href="https://pubmed.ncbi.nlm.nih.gov/18657380/">can be given a sedative</a> – something to make them more relaxed and less distressed at the end of life. We have recently <a href="https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15459">written about a third approach</a>: using a general anaesthetic to ensure that the dying patient is completely unconscious. This has been described previously, but largely overlooked.</p>
<p>There are two situations when a general anaesthetic might be used in dying patients. The first is when other drugs have not worked and the patient is still distressed or in pain. The second is when a patient has only a short time to live and expresses a clear wish to be unconscious. Some dying patients just want to sleep.</p>
<p>But what type of anaesthesia are we talking about? If you need surgery or a medical procedure, there are three options. First, being fully awake, but having local anaesthesia to block the pain. Second, you could be partly sedated: you would be less stressed or worried about it, but you might remember some of the procedure afterwards. Finally, you could have a general anaesthetic and be out cold, with no memory of the procedure afterwards.</p>
<p>Any of these might be appropriate, depending on the procedure and depending on the person. But the option with the highest chance that you won’t feel anything is, of course, general anaesthesia.</p>
<p>These same three options could be offered to a dying patient. Some people might want to be as awake as possible. (Like the poet Dylan Thomas, they might not wish to “<a href="https://poets.org/poem/do-not-go-gentle-good-night">go gentle into that good night</a>”.) Some might want to be sedated, if necessary. Others might want to be completely asleep.</p>
<p>The choice of general anaesthesia at the end of life is potentially popular. Last year, we <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0247193">surveyed more than 500 people</a> in the UK about end-of-life options. Nearly 90% said they would like the option of a general anaesthetic if they were dying. </p>
<p>You might wonder, is this not just euthanasia by another name? Giving someone medicines to ensure that they are unconscious as they die naturally is different from giving someone medicine to end their life. General anaesthesia is legal, whereas in many countries, including the UK, <a href="https://www.nhs.uk/conditions/euthanasia-and-assisted-suicide/">euthanasia is illegal</a>.
This means that the option of anaesthesia could be available now for dying patients in the UK without changing the law. France has recently recognised <a href="https://jme.bmj.com/content/44/3/204">the right for dying patients to be unconscious</a>.</p>
<h2>Wouldn’t it be too risky?</h2>
<p>There are side-effects with all medicines, but <a href="https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15459">recent advances</a> mean that it is possible to give anaesthetic medicines to patients close to death without affecting their breathing. The medicine is given slowly, and the patient made unconscious gradually over 15 to 20 minutes. The medicine can be slowed or stopped at any point.</p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/16376744/">Previous studies</a> that have used anaesthesia at the end of life, have continued the medicines for one to 14 days until the patient died naturally.</p>
<p>This will not be for everyone. It may not be possible for those who are dying in their own home. And some people will not want it. But we have the means to offer dying patients a gentle alternative end to their days. We believe that there is a strong ethical case to make the option of general anaesthesia at the end of life more widely available.</p><img src="https://counter.theconversation.com/content/159653/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dominic Wilkinson receives funding from the Wellcome Trust and the Arts and Humanities Research Council (AHRC) as part of the UK Research and Innovation rapid response to Covid-19: AH/V013947/1. The funders had no role in the preparation of this manuscript. </span></em></p><p class="fine-print"><em><span>Julian Savulescu receives funding from the Wellcome Trust, the Uehiro Foundation on Ethics and Education and the Arts and Humanities Research Council (AHRC) as part of the UK Research and Innovation rapid response to Covid-19: AH/V013947/1. The funders had no role in the preparation of this manuscript. </span></em></p>The case for letting people go gentle into that good night.Dominic Wilkinson, Consultant Neonatologist and Professor of Ethics, University of OxfordJulian Savulescu, Visiting Professor in Biomedical Ethics, Murdoch Children's Research Institute; Distinguished Visiting Professor in Law, University of Melbourne; Uehiro Chair in Practical Ethics, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1595412021-04-27T02:12:09Z2021-04-27T02:12:09ZHow lobed brain corals are helping solve the mystery of what general anaesthesia does to the brain<figure><img src="https://images.theconversation.com/files/397243/original/file-20210427-15-x9c6hz.jpg?ixlib=rb-1.1.0&rect=0%2C5%2C3872%2C2544&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Many of us will undergo general anaesthesia at some point in our lives — losing consciousness so we can be operated on painlessly. But although humans have used general anaesthesia for <a href="https://asa.org.au/history-of-anaesthesia/">more than 150 years</a>, we still don’t fully understand how it affects the brain. </p>
<p>To find out, we turned to a genus of stony coral called lobed brain coral (<em>Lobophyllia</em>). Using a unique fluorescent molecule present in lobed brain coral, we managed to isolate an important target of general anaesthetic drugs in fruit fly brains. Our <a href="https://www.eneuro.org/content/early/2021/04/14/ENEURO.0057-21.2021">findings</a> could help develop safer anaesthesia for humans. </p>
<h2>Glow-in-the-dark coral</h2>
<p>Lobed brain corals are bioluminescent, which means they can naturally produce and emit light. They’re found in the Indian and Pacific oceans, alongside other similar scientifically valuable creatures such as the crystal jelly <em>Aequorea victoria</em>. </p>
<figure class="align-center ">
<img alt="Crystal jelly Aequorea victoria" src="https://images.theconversation.com/files/396914/original/file-20210424-17-17sml4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/396914/original/file-20210424-17-17sml4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/396914/original/file-20210424-17-17sml4i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/396914/original/file-20210424-17-17sml4i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/396914/original/file-20210424-17-17sml4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/396914/original/file-20210424-17-17sml4i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/396914/original/file-20210424-17-17sml4i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"><em>Aequorea victoria</em> is a bioluminescent jellyfish found in the Pacific Ocean.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Bioluminescent ocean-dwellers have equipped researchers with a powerful toolkit of fluorescent molecules to study and track biological processes. They even inspired the Nobel Prize-winning discovery of the <a href="https://www.nobelprize.org/uploads/2018/06/advanced-chemistryprize2008.pdf">green fluorescent protein</a>.</p>
<p>The fluorescent molecule found in the lobed brain coral, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC528746/">Eos</a>, has a rather surprising feature: it can change colour. This lets scientists observe <a href="https://cdn.theconversation.com/static_files/files/1543/Dish4_Cell1_16000_Frames-file002-1.gif?1619331216">the movement of proteins</a> within living cells — something that was previously impossible.</p>
<p>Imagine you have a Christmas tree covered with lights but they were all lit the same colour; the tree might appear a bit blurry from afar. If one of the lights were to switch to a different colour, however, you’d spot it easily. </p>
<p>The same principles apply when scientists try to track moving proteins in cells. Proteins perform multiple vital tasks for a cell and tracking them can help us understand their function, but they’re usually too small to see with regular microscopes. </p>
<p>Using the Eos molecule, we can develop super-resolution microscopes that reveal even the smallest elements within cells, including proteins. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/397244/original/file-20210427-17-1icpgbs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/397244/original/file-20210427-17-1icpgbs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/397244/original/file-20210427-17-1icpgbs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/397244/original/file-20210427-17-1icpgbs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/397244/original/file-20210427-17-1icpgbs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/397244/original/file-20210427-17-1icpgbs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/397244/original/file-20210427-17-1icpgbs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/397244/original/file-20210427-17-1icpgbs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A multicoloured lobed brain coral (<em>Lobophyllia</em>) with yellow tips.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>A sleeping brain isn’t ‘inactive’</h2>
<p>Anaesthesia today generally involves injecting a patient’s vein with a dose of a sedative drug and painkiller. For instance, the combination of <a href="https://academic.oup.com/bjaed/article/16/8/276/2364847">propofol and fentanyl</a> will make you unconscious and prevent you from feeling pain.</p>
<p>Sedative drugs, including sleeping pills, use your brain’s natural ability to <a href="https://pubmed.ncbi.nlm.nih.gov/33857967/">put you to sleep</a>. They target the circuits in your brain that regulate wakefulness and stop them from being active. </p>
<p>However, the brain activity of a sleeping person is very different to that of someone under anaesthesia. A sleeping brain performs many tasks and is quite active. A brain under anaesthesia is <a href="https://pubmed.ncbi.nlm.nih.gov/29121293/">largely unresponsive</a>.</p>
<p>Why aren’t we able to be woken up while under general anaesthesia? To find out, scientists need to identify what else in the brain, apart from sleep pathways, is targeted by general anaesthetic drugs.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-our-brain-needs-sleep-and-what-happens-if-we-dont-get-enough-of-it-83145">Why our brain needs sleep, and what happens if we don’t get enough of it</a>
</strong>
</em>
</p>
<hr>
<h2>Anaesthesia stunts the brain’s processing power</h2>
<p>Neurons, the cells in the brain, communicate with each other through a process known as synaptic neurotransmission. This is the main way our brains process information.</p>
<figure class="align-right ">
<img alt="Synapse neurotransmitter release" src="https://images.theconversation.com/files/396902/original/file-20210424-17-jjukoj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/396902/original/file-20210424-17-jjukoj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/396902/original/file-20210424-17-jjukoj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/396902/original/file-20210424-17-jjukoj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/396902/original/file-20210424-17-jjukoj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/396902/original/file-20210424-17-jjukoj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/396902/original/file-20210424-17-jjukoj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Neurotransmission lets neurons to talk to one another and process information such as pain.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>For neurotransmission to occur, specialised proteins within neurons must release chemicals called neurotransmitters (such as dopamine or glutamate). Proteins are dynamic. They can move freely inside neurons and are often needed in different parts of the cell. </p>
<p>For our research, we <a href="https://doi.org/10.1523/ENEURO.0057-21.2021">took the Eos molecule</a> and attached it onto a protein called “syntaxin1A” — which is responsible for facilitating neurotransmission — to see how general anaesthetic drugs might affect its normal function in the brains of fruit flies.</p>
<p>We found syntaxin1A dynamics were altered with general anaesthetic drugs such as propofol and isoflurane. The protein became <a href="https://pubmed.ncbi.nlm.nih.gov/29320738/">trapped in clusters of proteins</a> and its movement was therefore restricted.</p>
<p>This may have been what reduced the efficiency of neurotransmission, preventing the brain from processing complex information. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/gene-editing-is-revealing-how-corals-respond-to-warming-waters-it-could-transform-how-we-manage-our-reefs-143444">Gene editing is revealing how corals respond to warming waters. It could transform how we manage our reefs</a>
</strong>
</em>
</p>
<hr>
<h2>A goal to develop new, safer drugs</h2>
<p>Many proteins apart from syntaxin1A are involved in neurotransmission. So it’s likely others are also affected by anaesthetic drugs. </p>
<p>This new way to observe individual protein behaviour in intact brain tissue will hopefully uncover more drug targets and explain the precise mechanisms that underpin general anaesthetics.</p>
<p>Consequently, this knowledge will aid in the development of safer drugs with fewer <a href="https://www.mayoclinic.org/tests-procedures/anesthesia/about/pac-20384568">side effects</a>. And targeted drug development could help prevent the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4864680/">abnormally long recovery times</a> observed in some patients who undergo general anaesthesia.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/396904/original/file-20210424-13-1yka7pm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/396904/original/file-20210424-13-1yka7pm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=451&fit=crop&dpr=1 600w, https://images.theconversation.com/files/396904/original/file-20210424-13-1yka7pm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=451&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/396904/original/file-20210424-13-1yka7pm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=451&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/396904/original/file-20210424-13-1yka7pm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=567&fit=crop&dpr=1 754w, https://images.theconversation.com/files/396904/original/file-20210424-13-1yka7pm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=567&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/396904/original/file-20210424-13-1yka7pm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=567&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Anaesthetic drug development will be enhanced once we better understand how these drugs affect us.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure><img src="https://counter.theconversation.com/content/159541/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bruno van Swinderen receives funding from the National Health and Medical Research Council (NHMRC)</span></em></p><p class="fine-print"><em><span>Adam David Hines does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Scientists still still don’t fully understand how general anaesthesia affects the brain and body. A molecule found in bioluminescent stony coral may shed some light.Adam David Hines, PhD Candidate, The University of QueenslandBruno van Swinderen, Professor, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1485612020-12-10T18:27:44Z2020-12-10T18:27:44ZHow to manage pain during childbirth: what the research says<figure><img src="https://images.theconversation.com/files/372604/original/file-20201202-23-10mn9br.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There are many ways to control pain.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/illustration-midwife-helping-woman-give-birth-1448398898">Ken Tackett/Shutterstock.com</a></span></figcaption></figure><p>Women have always used different methods to try and reduce pain during childbirth. Over the years these methods have included inhaling opiates, a warm compress, magical charms and even sprinkling animal dung in a <a href="https://link.springer.com/chapter/10.1007%2F978-1-4614-8441-7_62">hot drink</a>. </p>
<p>Anaesthesia started to be used in childbirth in the 1800s, typically involving ether or chloroform. Today, drugs such as nitrous oxide (gas and air), epidurals and pethidine are regularly used during labour. </p>
<p>Epidural is the most comprehensive option, a type of anaesthetic that is injected into the back, numbing the nerves that carry the pain impulses. Pethidine is injected into the thigh or buttock. It works as more of a relaxant, by mimicking the natural endorphins it reduces the transmission of pain signals sent by the nerves to the brain.</p>
<p>While natural “mind-body” methods (such as massage) have been used for aeons, in recent years more sophisticated strategies such as controlled breathing techniques, immersion in water and self-hypnosis have emerged. These methods started to be more <a href="https://journals.sagepub.com/doi/10.1177/0310057X150430S106">actively promoted</a> in the US and parts of Europe from the 1990s.</p>
<p>These two groups of pain relief methods (pharmacological and non-pharmacological) have different purposes. Anaesthesia aims to relieve labour pain, whereas natural methods aim to help women <a href="https://www.onlinelibrary.wiley.com/doi/abs/10.1016/j.jmwh.2010.02.001">cope with it</a>. But what does the research say about women’s experiences of pain relief and whether – and in what circumstances – these various relief methods actually work? </p>
<h2>One size doesn’t fit all</h2>
<p>In general, discussions of childbirth often centre on the <a href="https://theconversation.com/why-labour-is-such-a-pain-and-how-to-reduce-it-48092">pain women experience</a> during labour and birth, and rightly so, as how women are supported to cope or manage labour pain makes a difference to the immediate experience of childbirth and has a <a href="https://theconversation.com/mondays-medical-myth-women-forget-the-pain-of-childbirth-12271">long-lasting impact</a> on women’s wellbeing. But women’s <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-019-0735-4">needs and preferences</a> for how to manage pain during childbirth differs. </p>
<p>Some women plan to use some form of anaesthesia as they want to feel in control during labour and to have a <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-019-0735-4">pain-free birth</a>. They might make this <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-019-0735-4">decision</a> during pregnancy, either because of a previous positive experience of medications or a negative experience of an un-medicated birth, or for first-time mums, a fear of “unbearable pain”. </p>
<p>Other women make the <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-019-0735-4">decision</a> to use anaesthesia after labour has started, usually at a critical point where they feel out of control, exhausted and unable to cope with the pain. As the women in these situations are more likely to express feelings of <a href="https://pubmed.ncbi.nlm.nih.gov/28735031/">guilt and failure</a>, this is an area where more support and care is needed. </p>
<p>Women who choose mind-body methods usually want a vaginal, <a href="https://www.researchgate.net/publication/292835988_Music_as_a_conditioning_aid_in_the_childbirth_experience_A_qualitative_study">intervention-free birth</a>. This decision tends to be made during pregnancy, and some preparation is usually undertaken, such as attending a hypnobirthing <a href="https://www.nct.org.uk/labour-birth/getting-ready-for-birth/hypnobirthing-where-start">antenatal class</a>. However, it is important to note that natural methods are <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-019-0735-4">not always promoted</a>, offered or made possible by maternity care providers.</p>
<figure class="align-center ">
<img alt="Pregnant woman leans over a bed, comforted by two other women." src="https://images.theconversation.com/files/373053/original/file-20201204-23-1bjv1p0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/373053/original/file-20201204-23-1bjv1p0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/373053/original/file-20201204-23-1bjv1p0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/373053/original/file-20201204-23-1bjv1p0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/373053/original/file-20201204-23-1bjv1p0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/373053/original/file-20201204-23-1bjv1p0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/373053/original/file-20201204-23-1bjv1p0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A pregnant woman having contractions.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/auckland-june-07-2014pregnant-woman-having-200196065">ChameleonsEye/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>The evidence</h2>
<p>Pharmacological and non-pharmacological methods, when they meet women’s needs, can help women feel relaxed, calm, in control and even <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-019-0735-4">more energised</a> during labour. </p>
<p>Experiments have found that anaesthesia, particularly an epidural, can be effective in <a href="https://www.cochrane.org/CD009234/PREG_pain-management-for-women-in-labour---an-overview">reducing labour pains</a>. </p>
<p>But not all the evidence is positive. Some women continue to experience pain after an epidural has <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-019-0735-4">been administered</a>, referred to as “breakthrough pain”. Epidurals can also slow down a woman’s labour and can lead to <a href="https://www.cochrane.org/CD009234/PREG_pain-management-for-women-in-labour---an-overview">further interventions</a> such as delivery using forceps or ventouse (a suction device). </p>
<p>Other popular forms of anaesthesia such as gas and air, pethidine or remifentanil have also been found to cause side effects such as <a href="https://pubmed.ncbi.nlm.nih.gov/31874879/">dizziness and nausea</a>. Over the last decade or so, there have been developments in “patient-controlled” anaesthesia, with women able to push a button to receive doses of pain relief (such as remifentanil) as needed. Further studies into whether and how this method impacts on women’s experiences of pain relief, and how it compares to other forms of anaesthesia, are needed.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/why-labour-is-such-a-pain-and-how-to-reduce-it-48092">Why labour is such a pain – and how to reduce it</a>
</strong>
</em>
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<p>Natural methods also have a mixed evidence base. Experiments have found immersion in water, relaxation, acupuncture and massage can provide better <a href="https://www.cochrane.org/CD009234/PREG_pain-management-for-women-in-labour---an-overview">satisfaction with pain relief</a>, and some methods (relaxation and acupuncture) can lead to <a href="https://www.cochrane.org/CD009234/PREG_pain-management-for-women-in-labour---an-overview">less interventions</a> (such as forceps or caesarean births). In qualitative research, some women found natural methods <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-019-0735-4">less effective</a> in helping them to cope with their labour pain, and some mind-body methods such as hypnosis, mindfulness and aromatherapy <a href="https://www.cochrane.org/CD009234/PREG_pain-management-for-women-in-labour---an-overview">need more evidence</a>. </p>
<p>An interesting difference between the different types of pain relief is that when effective, anaesthesia can enable women to feel more connected with others in the birth room, whereas mind-body methods enable women to feel more connected to their <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-019-0735-4">bodily responses</a>. It is also important to note that being relieved of pain, does <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-019-0735-4">not necessarily</a> equate with satisfaction. A positive, satisfying birth is linked to women feeling safe, supported and respected regardless of their pain relief preferences. </p>
<h2>What matters most</h2>
<p>It is important to acknowledge that women’s experiences of pain are influenced by the relationships with their caregivers. When women are able to form a <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004667.pub4/full">trusting relationship</a> with their caregiver, they report more positive experiences of birth overall, regardless of the pain relief method used. </p>
<p>If women do not feel supported, this can cause <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-019-0735-4">stress and distress</a>. A lack of positive relationships or support from maternity care providers may increase the likelihood of a <a href="https://www.cambridge.org/core/journals/psychological-medicine/article/aetiology-of-posttraumatic-stress-following-childbirth-a-metaanalysis-and-theoretical-framework/10D8B61EB50E47820CEF4053800D0BE3">traumatic birth experience</a>. </p>
<p>Women need to have timely access to information about different pain-management methods, including the risks and benefits of each approach so that an informed decision can be made. Assumptions should also not be made regarding women’s <a href="https://www.bmj.com/content/368/bmj.m442?hwshib2=authn%3A1603270575%3A20201020%253A89ecb87d-e125-4e06-bb40-be31c4e1b5ee%3A0%3A0%3A0%3AboGa37sbeozvuZ7dhjrGKw%3D%3D">ethnicity</a>, <a href="https://www.jstor.org/stable/41675171?seq=1">class</a>, ability or <a href="https://www.birthrights.org.uk/campaigns-research/disability/">disability</a>. Research shows that women who face more complex issues can be further disadvantaged during childbirth, and are at greater risk of disrespectful care practices.
Doctors and midwives must be attuned to their <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5333436/">potential biases</a> to ensure all women receive equitable care. </p>
<p>Most of all, understanding and supporting individual needs is essential to <a href="https://www.whiteribbonalliance.org/wp-content/uploads/2017/11/Final_RMC_Charter.pdf">safe, respectful and dignified</a> maternity care.</p><img src="https://counter.theconversation.com/content/148561/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Anaesthesia aims to relieve labour pains, whereas natural methods aim to help women cope with it. What does the evidence say about the options?Gill Thomson, Professor in Perinatal Health, University of Central LancashireDr Claire Feeley, Postdoctoral Research Associate, University of Central LancashireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1179552019-05-30T12:50:47Z2019-05-30T12:50:47ZWhy thousands are getting hit with unexpected medical bills<figure><img src="https://images.theconversation.com/files/277069/original/file-20190529-192451-17ls4hb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Surprise medical bills are happening more frequently, often from an ER visit.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/indignant-angry-irritated-young-african-american-621332141?src=_9leL6GUgeqOJ7OyZFmCmw-1-3">Damir Khabirov/Shutterstock.com</a></span></figcaption></figure><p>Hardly a week goes by without <a href="https://www.kut.org/post/austin-teacher-hit-giant-hospital-bill-joins-trump-event-surprise-medical-billing">another story</a> in the media covering a family somewhere in America dealing with an outrageous medical bill. Yet, in more and more cases, these families don’t have <a href="https://theconversation.com/short-term-health-plans-a-junk-solution-to-a-real-problem-101447">junk insurance</a>, or lack coverage altogether. Indeed, they have what Americans would consider decent coverage, either through their employer or an <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/puar.12065">Affordable Care Act marketplace</a>. They also followed, or so they thought, the rules of their insurance policy requiring them to seek care inside their provider network. Yet, they are slapped with surprise bills, and often threatened by bankruptcy.</p>
<p>What gives?</p>
<p>In my view as a health care policy researcher, the increasing occurrence of surprise medical bills is not an accident. Rather, it is a reflection of a larger trend in the American health care system. There’s been a <a href="https://revcycleintelligence.com/news/major-healthcare-mergers-and-acquisitions-making-waves-in-2019">massive wave of consolidation in the health care business</a> to gain greater bargaining clout. These surprise bills are a byproduct of the wrangling between two sets of players – insurers and care providers – a battle of giants that often leaves patients holding the bill. </p>
<p><a href="https://www.healthaffairs.org/do/10.1377/hblog20190221.859328/full/">Recent efforts at the federal level</a> to provide protections to patients are long overdue. Yet, it is unclear whether patients will see any tangible outcomes, as insurers and providers are fiercely protecting their interests. Even if successful, these protections would likely only alleviate the most glaring problems of surprise bills untouched.</p>
<h2>What’s going on here?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/277071/original/file-20190529-192451-1tdgyzf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/277071/original/file-20190529-192451-1tdgyzf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/277071/original/file-20190529-192451-1tdgyzf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/277071/original/file-20190529-192451-1tdgyzf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/277071/original/file-20190529-192451-1tdgyzf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/277071/original/file-20190529-192451-1tdgyzf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/277071/original/file-20190529-192451-1tdgyzf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Patients in emergency rooms are receiving surprise bills more often than in years past.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/medical-team-working-on-patient-emergency-168768599?src=XbCgA882ahzyds2UFIBWEw-1-8">Monkey Business Images/Shutterstock.com</a></span>
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</figure>
<p>The story is nearly always the same. A patient, often in an emergency, receives care, as required by his or her insurance coverage, in a hospital that was part of their provider networks.</p>
<p>Patients usually assume that all doctors participating in their treatment in the facility are also covered in their network. However, while their primary providers may be part of their network, ancillary physicians with little or no contact with the patient, such as <a href="https://www.healthaffairs.org/do/10.1377/hblog20190521.144063/full/">anesthesiologists and radiologists</a>, may not be. And, in many hospitals, the very doctor who takes care of you in an emergency – the<a href="https://www.healthaffairs.org/do/10.1377/hblog20190521.144063/full/"> ER doctor</a> – may not have any insurance contracts whatsoever.</p>
<p>Patients may only realize their miscalculation when it’s too late – when “surprise” bills start arriving in the mail, often outrageously high, a few week later. Not even members of Congress are immune from the practice, as Rep. <a href="https://freebeacon.com/politics/rep-porter-congressional-clout-helped-erase-my-medical-bills/">Katie Porter</a>, D-Calif., experienced when she received a US$2,800 out-of-pocket bill after an appendectomy.</p>
<p>The results for patients are often devastating. While the full extent of the problem is unclear, studies have shown, <a href="https://www.healthaffairs.org/doi/10.1377/hlthaff.2016.0970">that about 20% of inpatient emergency department cases result in surprise bills</a>. Insurance companies will usually pay a part of the bill, but physicians then send the remainder directly to the patients. </p>
<p>The sums are often horrendous and bear little correspondence to the cost of the care provided: <a href="https://khn.org/news/the-remedy-for-surprise-medical-bills-may-lie-in-stitching-up-federal-law/">$229,000 for spinal fusion surgery</a>, <a href="https://www.nytimes.com/2014/09/21/us/drive-by-doctoring-surprise-medical-bills.html">$117,000 for neck surgery</a>, or <a href="https://www.nytimes.com/2014/09/21/us/drive-by-doctoring-surprise-medical-bills.html">$250,000 for back surgery</a>. These are bills after insurance companies paid for part of the bill. And of course, the threat of being turned over to a <a href="https://khn.org/news/people-with-medical-debt-most-likely-to-be-dunned-by-collection-agencies/">collection agency</a> looms largely over patients’ heads, with medical debt typically listed as the primary reason for being contacted by a collection agency.</p>
<h2>The larger picture: Battle of the giants</h2>
<p>The <a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.22.3.89">distinguishing characteristic of the U.S. health care system is its high cost</a>: Americans simply pay more for health care than their counterparts in the developed world.</p>
<p>Given the dual threats of high costs and large uncertainties, Americans have long relied on insurance arrangements when it comes to financing their health care needs. As a result, patients today are trapped between two massive bureaucracies intent on maximizing their income: providers and insurers.</p>
<p>For decades, Americans and public payers have, by-and-large, accepted accelerating health care costs. Yet, with costs <a href="https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nationalhealthaccountshistorical.html">around 18% of GDP</a> and <a href="https://www.macpac.gov/subtopic/medicaids-share-of-state-budgets/">exerting intense pressure of public and private budgets</a>, the health care sector has drawn greater scrutiny.</p>
<p>As a result, pressure to contain costs have begun to emerge, leading to intensifying conflict between the two entities. More recently, these developments have triggered significant and increasing consolidation efforts on both sides.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/277073/original/file-20190529-192394-1wi0mqb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/277073/original/file-20190529-192394-1wi0mqb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=413&fit=crop&dpr=1 600w, https://images.theconversation.com/files/277073/original/file-20190529-192394-1wi0mqb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=413&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/277073/original/file-20190529-192394-1wi0mqb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=413&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/277073/original/file-20190529-192394-1wi0mqb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=519&fit=crop&dpr=1 754w, https://images.theconversation.com/files/277073/original/file-20190529-192394-1wi0mqb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=519&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/277073/original/file-20190529-192394-1wi0mqb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=519&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A CVS sign in Ridgeland, Miss.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Earns-CVS/13d76983c9304c94a79bbbedfdedc2b9/30/0">Rogelio V.. Solis/AP Photo</a></span>
</figcaption>
</figure>
<p>Health insurers are seeking mergers with other insurers. Recent examples include <a href="https://www.latimes.com/business/la-fi-centene-buys-wellcare-20190327-story.html">Centene buying WellCare</a> but also <a href="https://money.cnn.com/2018/03/08/investing/health-care-mergers-cigna-express-scripts-consolidation/index.html">Cigna’s ill-fated attempt to merge with Anthem</a> and <a href="https://money.cnn.com/2018/03/08/investing/health-care-mergers-cigna-express-scripts-consolidation/index.html">Aetna’s and Humana’s aborted consolidation attempt</a>. </p>
<p>Insurers are also attempting to expand beyond their traditional role into the direct provision of services, including <a href="https://money.cnn.com/2018/03/08/investing/health-care-mergers-cigna-express-scripts-consolidation/index.html">Aetna’s efforts to team up with drugstore chain CVS</a>, and <a href="https://money.cnn.com/2018/03/08/investing/health-care-mergers-cigna-express-scripts-consolidation/index.html">Cigna merging with Express Scripts</a>. Insurers are trying to get greater market power, not only versus other insurers, but perhaps even more prominently, against other stakeholders in the health care sector.</p>
<p>On the other hand, providers have not been idle either. <a href="https://revcycleintelligence.com/news/major-healthcare-mergers-and-acquisitions-making-waves-in-2019">Mergers and acquisitions are at an all-time high</a>. <a href="https://www.kaufmanhall.com/ideas-resources/research-report/2018-ma-review-new-healthcare-landscape-takes-shape">Hospitals are merging with other hospitals</a>. But they are also <a href="https://www.beckershospitalreview.com/lists-and-statistics/15-growing-healthcare-systems.html">investing heavily in construction activities</a>, <a href="https://www.beckershospitalreview.com/lists-and-statistics/15-growing-healthcare-systems.html">expanding or purchasing physician groups</a> and <a href="https://www.beckershospitalreview.com/lists-and-statistics/15-growing-healthcare-systems.html">ambulatory and specialty surgery centers</a>, as well as <a href="https://www.beckershospitalreview.com/lists-and-statistics/15-growing-healthcare-systems.html">imaging, diagnostic and laboratory services</a>.</p>
<p>Both sides have sought to capitalize on their increasing clout.</p>
<p>Many providers have sought to utilize their new market powers to gain concessions from insurers in the form of larger reimbursements for patient care. Insurers, for their part, have resisted these demands where possible. Most importantly, they have started to deliberately exclude certain high-cost providers from their networks. These range from <a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2014.1406">prominent hospitals like Cedars-Sinai</a> to <a href="https://journals.sagepub.com/doi/full/10.1177/2333392818824472">rural specialists like endocrinologists</a>.</p>
<p>In this struggle, certain providers – those you do not have a choice in selecting, such as <a href="https://www.healthaffairs.org/do/10.1377/hblog20190521.144063/full/">emergency room doctors, anesthesiologists and radiologists</a> – hold a more pivotal role in the provision of health care. To maximize their profits, they often have deliberately chosen not to contract with any insurers.</p>
<p>As insurers reduce the number of providers in their networks, <a href="https://jamanetwork.com/journals/jama/fullarticle/2367284?linkId=16227536">patients benefit from lower premiums</a>. However, <a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2014.1406">with fewer providers to see for treatment</a> patients are, of course, more likely to obtain treatment out-of-network.</p>
<p>As insurers and providers push back on paying bills for care, patients usually end up holding the bill.</p>
<h2>Is Congress fixing the mess?</h2>
<p>Surprise bills are nothing new. However, patients caught between two massive competing bureaucracies offers a compelling narrative for policymakers. The issue of surprise medical bills has been so outrageous that Democrats and Republicans in Washington, D.C., and across state legislatures, have started to work together to offer patients with some sort of protection.</p>
<p>So far, <a href="https://www.commonwealthfund.org/publications/issue-briefs/2017/jun/balance-billing-health-care-providers-assessing-consumer">some 20 states</a> have established various forms of consumer protections. These protections differ significantly, and often are rather limited. Moreover, these protections are significantly limited by the reach of state regulators, leaving many Americans largely unprotected. </p>
<p>The federal government is starting to the jump on the bandwagon. The recent proposal <a href="https://www.help.senate.gov/imo/media/doc/LHCC%20Act%20Discussion%20Draft%205_23_2019.pdf">by Sens. Patty Murray and Lamar Alexander</a> serves just as <a href="https://www.healthaffairs.org/do/10.1377/hblog20190221.859328/full/">the last example</a>.</p>
<p>And yet, surprise bills are merely the tip of the iceberg of what ails the American health care system. Current proposals leave other issues, such as <a href="https://www.dropbox.com/s/ydja9ez0alh9zz7/Haeder%20et%20al%20Forthcoming%20Gordian%20Knot.pdf?dl=0">inadequate networks</a> and <a href="https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2015.1554">inaccurate provider directories</a> largely untouched.</p>
<p>Ultimately, I think we need more comprehensive solutions that address the excessive costs of the broken U.S. health care system. Everything else, while crucial to individual patients, fails to offer substantial systemwide improvements.</p><img src="https://counter.theconversation.com/content/117955/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder is a Fellow in the Interdisciplinary Research Leaders Program, a national leadership development program supported by the Robert Wood Johnson Foundation to equip teams of researchers and community partners in applying research to solve real community problems. </span></em></p>A trip to the emergency room can turn expensive fast if the providers are not in your network. That is happening more often, as some doctors choose to opt out of insurance plans. Here’s why.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1156972019-05-14T22:50:22Z2019-05-14T22:50:22ZKetamine: The illicit party psychedelic that promises to heal depression<figure><img src="https://images.theconversation.com/files/273668/original/file-20190509-183077-1whnt10.jpg?ixlib=rb-1.1.0&rect=83%2C330%2C2483%2C1521&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ketamine is effective for those who do not respond to traditional anti-depressants. It also shows promise for the treatment of PTSD and bipolar disorder. </span> <span class="attribution"><span class="source">(Unsplash/Kal Visuals)</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>It’s been 50 years in the making, but the anaesthetic and illicit party drug ketamine is now having a clinical comeback. New studies show that this commonly used anaesthetic can provide quick relief of core symptoms associated with severe depression, including <a href="https://www.cbc.ca/radio/april-13-2019-black-hole-imaged-a-new-tiny-human-rebuilding-coral-reefs-and-more-1.5093713/ketamine-works-its-magic-on-depression-by-stabilizing-the-brain-in-a-well-state-1.5093729">suicidal ideation</a>. </p>
<p>Amazingly, ketamine works within hours and its <a href="https://doi.org/10.1001/archpsyc.63.8.856">effects are maintained for at least one week</a>. Most strikingly, ketamine is effective in those patients who are <a href="https://doi.org/10.1176/appi.ajp.2013.13030392">resistant to ordinary antidepressants</a>, and they make up around <a href="https://doi.org/10.3310/hta18310">30 to 50 per cent of the depressed population</a>.</p>
<p>Now, efforts in <a href="https://doi.org/10.1111/pcn.12675">Mexico</a>, <a href="https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12616001096448">Australia</a>, <a href="https://doi.org/10.1016/j.psychres.2015.10.032">France</a>, <a href="https://doi.org/10.1016/j.biopsych.2018.02.1052">Canada</a> and the <a href="https://doi.org/10.1016/j.biopsych.2009.04.029">United States</a>, among others, are focusing on understanding exactly how ketamine does this, and to what extent it is safe and effective in a clinical setting. Together, these studies will increase our understanding of depression around the world and perhaps expand ketamine’s potential to treat other forms of mental illness as well.</p>
<p>The focus of <a href="https://www.uoguelph.ca/psychology/users/francesco-leri">our lab at the University of Guelph</a> is to understand how specific drugs, such as ketamine, work in the brain and influence behaviour. </p>
<p>My doctoral research, specifically, looks at <a href="https://www.researchgate.net/profile/Brett_Melanson2">the link between stress, inflammation and behaviour</a>. I am studying how ketamine influences behaviour and can reduce the effects of stress, and what this means for mood disorders, such as major depression.</p>
<h2>The first dissociative anaesthetic</h2>
<p>Initially, ketamine was developed as an alternative to the well-known, illegal party drug, phencyclidine (PCP). In the late 1950s, PCP was the focus of Parke-Davis pharmaceuticals for its use as an anesthetic. However, the drug came with <a href="https://doi.org/10.1097/ALN.0b013e3181ed09a2">uncomfortable side effects</a> such as delirium and a loss of feeling in the limbs, which lasted for several hours after the drug was taken.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/273394/original/file-20190508-183083-i63nor.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/273394/original/file-20190508-183083-i63nor.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/273394/original/file-20190508-183083-i63nor.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/273394/original/file-20190508-183083-i63nor.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/273394/original/file-20190508-183083-i63nor.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/273394/original/file-20190508-183083-i63nor.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/273394/original/file-20190508-183083-i63nor.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Ketamine is known as the party drug Special K.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>To fix this issue, Cal Bratton of Parke-Davis encouraged scientists to look into possible ways to modify PCP, with a primary goal of reducing side effects. In 1962, the organic chemist, Calvin Stevens, made a PCP-like compound which he said had similar anaesthetic properties, with shorter acting psychoactive effects than PCP. </p>
<p>This compound, <a href="https://doi.org/10.1097/ALN.0b013e3181ed09a2">originally known as CI-581</a>, was eventually named <a href="https://doi.org/10.1097/EJA.0000000000000638">ketamine</a> based on the ketone and amine group that formed its chemical structure.</p>
<p>Followings its discovery, ketamine was then used in the first human trials in the mid-1960s which included testing on <a href="https://doi.org/10.1111/j.1365-2044.1990.tb14287.x">volunteer inmates of Jackson Prison</a> in Michigan, United States. </p>
<p>After consistent reports of feeling “disconnected” from the environment when given ketamine, it was classified as the first <a href="https://doi.org/10.1097/ALN.0b013e3181ed09a2">dissociative anesthetic</a>. </p>
<p>In the years after its initial testing, the effects of ketamine rapidly gained popularity around the globe, and the approval as a human anaesthetic was passed by the U.S. Food and Drug Administration (FDA) in 1970 — <a href="https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm">to be sold as Ketalar</a>.</p>
<h2>Unique antidepressant effect</h2>
<p>Recent studies describing ketamine’s antidepressant properties have led to a dramatic shift in how we view the drug and treat mental illness.</p>
<p>Typical antidepressants work by controlling levels of neurotransmitters in the brain known as monoamines, such as serotonin and norepinephrine. Ketamine’s antidepressant effect is unique, as it <a href="https://doi.org/10.1016/j.psychres.2014.10.028">modifies the activity of glutamate</a>, which is the main excitatory neurotransmitter in the brain and is not a monoamine.</p>
<p>One of the fascinating findings about ketamine is that it can rapidly reduce depressive symptoms in <a href="https://www.ncbi.nlm.nih.gov/books/NBK487457/pdf/Bookshelf_NBK487457.pdf">patients who do not respond to typical monoamine antidepressants</a>. This suggests the role of glutamate in depression.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/273667/original/file-20190509-183112-e1i9bo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/273667/original/file-20190509-183112-e1i9bo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/273667/original/file-20190509-183112-e1i9bo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/273667/original/file-20190509-183112-e1i9bo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/273667/original/file-20190509-183112-e1i9bo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/273667/original/file-20190509-183112-e1i9bo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/273667/original/file-20190509-183112-e1i9bo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The study of ketamine is opening new doors for treating mental illness.</span>
<span class="attribution"><span class="source">(Unsplash/Candice Picard)</span></span>
</figcaption>
</figure>
<p>In fact, studies have related ketamine’s antidepressant effect with its ability to maintain connections between neurons (or nerve cells) in the brain. These connections are known to continuously change in response to our environment, which is a process known as <em>plasticity</em>. Interestingly, the ability of these neurons to change connections highly relies on normal glutamate activity. </p>
<p>A combination of human and animal studies suggest that ketamine’s antidepressant effect may involve regulating glutamate levels to <a href="https://doi.org/10.4103/1673-5374.230288">strengthen these connections</a> and/or restore them <a href="https://www.bbrfoundation.org/event/brain-plasticity-effects-antidepressants-major-depression">back to a pre-stressed state</a>.</p>
<p>Further study of ketamine’s ability to restore these neural connections and how glutamate relates to mood disorders will surely open new doors for understanding mental illness.</p>
<h2>Nasal sprays and biomarkers</h2>
<p>Current research has shown positive effects of ketamine for other forms of mental illness as well, such as <a href="https://doi.org/10.4088/JCP.17m11634">post-traumatic stress disorder (PTSD)</a> and <a href="https://doi.org/10.9740/mhc.2017.01.016">bipolar disorder</a>. Though the results seem quite positive, more studies are required to validate their use beyond depression. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/273395/original/file-20190508-183103-1t9fg1i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/273395/original/file-20190508-183103-1t9fg1i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/273395/original/file-20190508-183103-1t9fg1i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/273395/original/file-20190508-183103-1t9fg1i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/273395/original/file-20190508-183103-1t9fg1i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=507&fit=crop&dpr=1 754w, https://images.theconversation.com/files/273395/original/file-20190508-183103-1t9fg1i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=507&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/273395/original/file-20190508-183103-1t9fg1i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=507&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A vial of ketamine.</span>
<span class="attribution"><span class="source">(AP Photo/Teresa Crawford)</span></span>
</figcaption>
</figure>
<p>Other studies using a <a href="https://doi.org/10.1176/appi.ajp.2018.18070834">repeated treatment method over several weeks</a> showed that ketamine can produce long-term reductions in symptoms of treatment-resistant depression, lending potential to its safety and effectiveness over longer periods of treatment.</p>
<p>Recently, the FDA has approved esketamine (ketamine’s “close cousin”) in the U.S., sold as <a href="https://www.cnn.com/2019/03/05/health/esketamine-depression-nasal-spray-fda-bn/index.html">Spravato</a> in the form of a nasal spray. Importantly, the spray is only prescribed to treatment-resistant patients who continue to take an oral antidepressant and can only be used under the supervision of a health-care provider.</p>
<p>Finally, studies are also looking into <a href="https://www.mayoclinic.org/medical-professionals/psychiatry-psychology/news/ketamine-research-focuses-on-mechanisms-of-action-and-biomarker-development/mac-20430311">biological markers that can predict response to treatment, also known as biomarkers</a>. If successful, this research would allow for more accurate and effective treatment delivery in the form of <a href="https://www.canbind.ca/research/why-and-how-we-study-depression/">personalised treatment plans</a>.</p>
<p>Increasing accessibility to ketamine treatment for depression will be the next major milestone for this drug. It is sure to provide effective relief for those who continue to experience treatment-resistant and severe depression.</p>
<p><br>
<br></p>
<p><em>The promise of ketamine for treating mood disorders only applies in a carefully monitored clinical setting. The street drug <a href="https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/ketamine">Special K can be addictive, put users at high risk and cause long-term psychological harm</a>.</em></p><img src="https://counter.theconversation.com/content/115697/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Brett Melanson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Research shows that ketamine can produce long-term reductions in symptoms of treatment-resistant depression.Brett Melanson, PhD Student in Neuroscience and Applied Cognitive Science, University of GuelphLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1166932019-05-09T12:57:22Z2019-05-09T12:57:22ZNumbing a body part can boost sensory powers elsewhere – here’s what that tells us about the brain<figure><img src="https://images.theconversation.com/files/273525/original/file-20190509-183096-10mqt12.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If one of your hands is anaesthetised, the remaining one will be better at touch perception.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/womans-hand-touch-young-wheat-ears-285318626?src=l4tYP0kH5KaU1UmwjkIosQ-1-10">AlexMaster/Shuttestock</a></span></figcaption></figure><p>When you wake up in the middle of the night in total darkness, it can feel as if
you have auditory superpowers. Suddenly, you can hear floorboards creak storeys below and the softest rustle of foxes destroying the bins outside, once again. Indeed, it is common wisdom that when you lose one sense, the remaining senses heighten.</p>
<p>Research with people experiencing long-term sensory deprivation, such as blindness or deafness, appears to support this notion. People born without sight can indeed <a href="http://www.jneurosci.org/content/23/8/3439.short">feel</a> and <a href="https://www.sciencedirect.com/science/article/pii/S0028393209003340">hear</a> things significantly beyond the range of the sighted.</p>
<p>Brain data initially seemed to explain these sensory superpowers. When a major sensory input is lost, the brain area that would have supported the missing sense now becomes active to other inputs. This can happen <em>across</em> sensory systems – like <a href="https://www.ncbi.nlm.nih.gov/pubmed/15772968">visual areas activating to touch</a> in the blind. But it can also happen <em>within</em> sensory systems – such as the brain area of an amputated hand becoming <a href="https://elifesciences.org/articles/01273">more responsive to touch</a> on the opposite hand or the remaining part of the amputee’s arm. It was <a href="https://www.ncbi.nlm.nih.gov/pubmed/19935836">long assumed</a> that more brain space meant more processing power and, therefore, should also mean enhanced perceptual powers for the invading sense.</p>
<p>While this is still the consensus across the scientific world, the idea is starting to attract some <a href="https://www.ncbi.nlm.nih.gov/pubmed/28214130">unexpected controversy</a>. Our new paper, published in the <a href="https://psycnet.apa.org/fulltext/2019-19962-006.pdf">Journal of Experimental Psychology: General</a>, has shed some light on the problem.</p>
<p>One reason behind the recent controversy is that sensory enhancement in blind individuals may simply result from their dependence on touch to get by, and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3159519/">increased exposure</a> to fine tactile discrimination, such as braille. Indeed, scientists have been able to train people with intact vision to show <a href="https://link.springer.com/article/10.3758/BF03205550">similarly impressive touch discrimination</a> as blind people, with sufficient training. That is, it may not be that case that blind people are using their visual cortex to process touch at all.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/273528/original/file-20190509-183112-1u4erzp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/273528/original/file-20190509-183112-1u4erzp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/273528/original/file-20190509-183112-1u4erzp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/273528/original/file-20190509-183112-1u4erzp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/273528/original/file-20190509-183112-1u4erzp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/273528/original/file-20190509-183112-1u4erzp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/273528/original/file-20190509-183112-1u4erzp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Braille.</span>
<span class="attribution"><span class="source">Nixx Photography/Shutterstock</span></span>
</figcaption>
</figure>
<p>Other studies have found no evidence of sensory deprivation boosting sensory perception where it would be expected (for example, in <a href="https://link.springer.com/article/10.3758/BF03208032">blindness</a> or following <a href="https://academic.oup.com/brain/article/125/6/1256/290401">amputation</a>).</p>
<h2>The experiment</h2>
<p>To dig deeper, we experimentally caused temporary sensory deprivation in a group of volunteers and compared the results with those of a control group – a total of 36 participants. Using a simple anaesthetic – Lidocaine, like you get at the dentist – we blocked touch and movement perception of a single finger of our participants. The anaesthetic was applied twice (on consecutive days), and lasted about two hours.</p>
<p>We found that this very small period of deprivation lead to significant improvements in touch perception of the finger directly adjacent to the anaesthetised finger, with no changes in the other digits. Why just the neighbouring finger? Research with primates shows that when one finger is lost, it’s <a href="https://www.ncbi.nlm.nih.gov/pubmed/6725633">mostly the neighbouring fingers</a> that claim the missing finger brain territory.</p>
<p>Our results show that the brain immediately boosted touch perception in one of the remaining fingers of our “temporary finger amputees” – suggesting short term deprivation can indeed have functional benefits for perception, without training.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/273524/original/file-20190509-183109-1jjq6se.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/273524/original/file-20190509-183109-1jjq6se.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/273524/original/file-20190509-183109-1jjq6se.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/273524/original/file-20190509-183109-1jjq6se.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/273524/original/file-20190509-183109-1jjq6se.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/273524/original/file-20190509-183109-1jjq6se.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/273524/original/file-20190509-183109-1jjq6se.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The brain responds to an anaesthetised and a lost finger in the same way.</span>
<span class="attribution"><span class="source">Jarva Jar/Shutterstock</span></span>
</figcaption>
</figure>
<p>What’s more, in another group, we showed that blocking touch perception on the index finger boosted the effect of a sensory training procedure applied to the middle finger – its effects were more widespread across the hand than in a non-anaesthetised group.</p>
<h2>Stroke rehabilitation and beyond</h2>
<p>These results are exciting as – unlike some past studies – we can actually show that sensory deprivation has different, and separable effects when used by itself, and when used to <a href="https://theconversation.com/can-you-train-yourself-to-develop-super-senses-86172">boost the effects of sensory training</a>. </p>
<p>Crucially, this holds promising implications for rehabilitation following brain damage. For example, sensory function of a hand affected by stroke <a href="https://www.ncbi.nlm.nih.gov/pubmed/16358329">can be improved by a sensory block</a> of the opposite, unaffected hand. It also helps us understand a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4361809/">popular therapy for stroke</a> that requires the unaffected arm to be bound, forcing use of the affected arm. It may be that this works partly thanks to the sensory and motor deprivation resulting from the “good arm” being bound. If this can be shown to truly be the case, we can use this knowledge to further push what this therapy can achieve. </p>
<p>The research can also help us answer a bigger question in neuroscience. While we show that sensory brain resources can be reallocated within a sensory modality – meaning a finger can use the brain territory of another finger to support touch perception – it remains unclear whether the brain can learn to reuse an area designed to support a different sense. So we still haven’t shown whether the vision area of the brain could be used for a completely different purpose. <a href="https://www.ncbi.nlm.nih.gov/pubmed/28214130">Very new perspectives</a> suggest that this kind of reorganisation might be too extreme, and brain areas are limited to the general functions they were designed for. </p>
<p>While nobody denies that there are changes in brain activity after sensory deprivation, it is unclear whether such changes are necessarily “functional” – affecting how we move, think or behave. But we are certainly edging closer to understanding the complicated brain processes that enable the sensory experiences that ultimately make life worth living.</p><img src="https://counter.theconversation.com/content/116693/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Harriet Dempsey-Jones does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New research involving temporary ‘finger amputations’ raises hope for more effective stroke rehabilitation.Harriet Dempsey-Jones, Postdoctoral Researcher in Cognitive Neurosciences, UCLLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1133402019-03-28T10:39:54Z2019-03-28T10:39:54ZThe surprising (and Long) story of the first use of ether in surgery<figure><img src="https://images.theconversation.com/files/265132/original/file-20190321-93060-1qbsng1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An illustration of Crawford Long removing a tumor from the neck of James Venable. </span> <span class="attribution"><span class="source">Crawford W. Long Museum</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>In the small town of Jefferson, Georgia, about 20 miles from the University of Georgia in Athens, a 26-year-old physician named Crawford Williamson Long removed a tumor from the neck of a man named James Venable while Venable was anesthesized with ether. The date was March 30, 1842. </p>
<p>More than four years later, in Boston, Massachusetts, on Oct. 16, 1846, <a href="https://www.britannica.com/biography/William-Thomas-Green-Morton">Thomas Morton</a>, a dentist using ether, served as anesthesiologist while Dr. John Warren, a surgeon at Boston’s Massachusetts General Hospital, performed surgery on a patient’s neck. </p>
<p>A physician observer rushed the news to local newspapers and medical journals, and thus history was written – inaccurately.</p>
<p>For years, Massachusetts General Hospital, Boston’s storied hospital that is Harvard’s main teaching hospital, has featured “<a href="https://www.massgeneral.org/museum/exhibits/etherdome/">the Ether Dome</a>,” the site of what many believed was the first surgery using ether. A donor provided money to the city of Boston to erect an “<a href="http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1931389">Ether Monument</a>,” which was installed in 1868. And for years, medical historians credited Morton with the accomplishment of being the first person to use ether to anesthetize a patient.</p>
<p>But it wasn’t true. Crawford Long deserved the credit.</p>
<p>Morton toiled unsuccessfully for years to get the U.S. Congress to recognize his “discovery” and grant him a monetary award. He tried to disguise his ether with odorants and coloring agent, even naming it <a href="http://anesthesiology.pubs.asahq.org/selfserve/sspage.aspx?selfservecontentid=letheon">“Letheon</a>,” after the river in Greek mythology believed to induce forgetfulness, in his unsuccessful effort to patent it. “Letheon” was quickly identified as ether, which was in the public domain. </p>
<p>I became interested in the story of Long and ether while I was teaching “History of Psychology” in a building at the University of Georgia that bore a plaque commemorating Long’s discovery of anesthetic ether. The textbook I was using did not mention Long but credited Thomas Morton of Boston. Naturally, that aroused my curiosity, and I have been <a href="https://faculty.franklin.uga.edu/rkthomas/sites/faculty.franklin.uga.edu.rkthomas/files/LongEther16March2016.pdf">interested in Long ever since</a>.</p>
<p>While most academics are well aware of the warning to publish or perish, you could say that Long’s case was an example of publish or almost relinquish your place in history. Long delayed publication for seven years for what he considered to be very good reasons, but by delaying, he gave Morton a chance to try to steal his priority. </p>
<h2>A painful procedure</h2>
<p>In the early 19th century, there were few options for pain-free surgery. <a href="http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1972552">Mesmerism</a>, or hypnosis, was used, and some medical schools offered instruction for inducing mesmerism. However, mesmerism was considered unreliable.</p>
<p>The discovery of something to prevent horrible pain during surgery was thus hailed as almost a medical miracle.</p>
<p>After <a href="https://www.georgiaencyclopedia.org/articles/science-medicine/crawford-long-1815-1878">Long earned his degree</a> at the University of Georgia, he apprenticed in medicine with Dr. George Grant in Jefferson. Long then studied medicine at Transylvania University in Lexington, Kentucky, and at the University of Pennsylvania. After gaining further surgical experience in New York City, Long considered joining the U.S. Navy as a surgeon. However, his father persuaded him to return to Georgia, and Long purchased Dr. Grant’s practice in Jefferson.</p>
<p>Long got the idea to use ether in 1842, and Venable was likely convinced to try it, because both had <a href="https://doi.org/10.1136/bmj.f3861">participated in the recreational use</a> of ether in what was known at the time as “ether frolics.” The frolics, which were socially acceptable even for the physicians and pharmacists who provided the ether, involved inhalation of ether, but not to the extent of unconsciousness. Long observed that he had falls and blows during ether frolics without the pains that were likely when one had not inhaled ether. </p>
<p>Long’s surgery on Venable was successful, but he delayed publication in the <a href="https://augusta.openrepository.com/augusta/handle/10675.2/729">Southern Medical and Surgical Journal</a> until 1849.</p>
<p>Yet medical historians, some as recently as the 1990s, diminished Long’s discovery. Some historians even suggested wrongly that Long did not realize the significance of what he had done.</p>
<p>In 1912, famed physician <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3277340/">Sir William Osler</a>, credited with helping to create modern medical education practices, <a href="https://babel.hathitrust.org/cgi/pt?id=chi.16616738;view=1up;seq=230">wrote</a>: </p>
<p>“Long of Georgia made patients inhale the vapor until anesthetic and
had performed operations upon them in his state, but it was not until October 16, 1846, in the Massachusetts General Hospital, that Morton in a public operating room, rendered a patient insensible with ether and demonstrated the utility of surgical anesthesia.”</p>
<p>In 1997, <a href="https://faculty.franklin.uga.edu/rkthomas/sites/faculty.franklin.uga.edu.rkthomas/files/LongEther16March2016.pdf">V. C. Saied wrote</a>:</p>
<p>“It is significant that Dr. Crawford Long of Jefferson, Georgia…had been using ether anesthesia in 1842, 4 years before Morton’s public demonstration…However, his (Long) keeping it isolated…and failing to promote ether as anesthesia only prolonged worldwide suffering.” </p>
<p>Long’s seven-year delay in publishing, apparently, biased the historians. When he finally did publish in 1849, Long wrote that he had not wanted to inflict possible misinformation upon the world if he was wrong about ether. </p>
<p>He cited three reasons for his delay. </p>
<p>First, he noted although he was not a believer in mesmerism, he needed more cases to ensure that somehow the patient had not self-mesmerized. In his small country practice, it took several years to accumulate sufficient evidence. </p>
<p>Second, when Long read of Morton’s claim of first use of ether, he felt it was prudent to see if other claims would be forthcoming that predated his. </p>
<p>Third, he finally accumulated enough cases, including controls. In one case, three tumors were removed from a patient on the same day. Tumors one and three were removed without ether, and tumor two with ether. Only the removal of tumor two was painless.</p>
<p>Two years later, Long amputated two fingers from a boy on the same day, one with and one without ether, and only the amputation with ether was painless.</p>
<p>Long also reported a few other cases before 1849 where surgery involving ether was pain free.</p>
<h2>Above it all</h2>
<p>In 1846, when Morton administered ether to the patient at Massachusetts General Hospital, the surgical theater was on the top of the building under a glass-covered dome for its optimal lighting. Today, MGH maintains the “Ether Dome” as a museum, saying that it was the site of the “first public demonstration” of anesthetic ether. There is also a monument in Boston’s Public Garden, on one side of which is the inscription, “To commemorate the discovery that the inhaling of ether causes insensibility to pain. First proved at Mass. General Hospital in Boston October AD MDCCCXLVI.” </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/265701/original/file-20190325-36267-11w4lae.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/265701/original/file-20190325-36267-11w4lae.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/265701/original/file-20190325-36267-11w4lae.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/265701/original/file-20190325-36267-11w4lae.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/265701/original/file-20190325-36267-11w4lae.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1006&fit=crop&dpr=1 754w, https://images.theconversation.com/files/265701/original/file-20190325-36267-11w4lae.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1006&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/265701/original/file-20190325-36267-11w4lae.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1006&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The Ether Monument in Boston’s Public Garden.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Ether_Monument_in_Boston_Public_Garden_inscription.jpg">Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>The claim on the monument is untrue, but it’s hard to change something carved in granite. I also question Mass. General’s claim for the “first public demonstration” of the use of anesthetic ether. Long’s use of anesthetic ether in 1842 was conducted in his public access office, and he had six witnesses. Regardless of any controversy, Friedman’s and Frieldland’s Medicines 10 Greatest Discoveries (1998), Chapter 5 is “Crawford Long and Surgical Anesthesia.”</p>
<p>In its early days, the ether monument raised controversy.</p>
<p>Morton and his chemist, Dr. Charles T. Jackson, had long argued over credit for the discovery, with <a href="https://www.britannica.com/biography/Charles-Thomas-Jackson">Jackson denouncing Morton</a> as a “swindler.” Morton even refused half of a <a href="https://www.mayoclinicproceedings.org/article/S0025-6196(12)61524-9/pdf">5,000-franc prize</a> from the French Academy of Medicine awarded jointly to him and Jackson because he insisted the award was his alone. </p>
<p><a href="http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1931389">Mark Twain and Dr. Oliver Wendell Holmes</a> weighed in on the matter, with Holmes writing that the monument was to “ether or either.” Twain opposed Morton’s claims, writing that “the monument is made of hardy material, but the lie it tells will outlast it a million years.”</p>
<p>A statue of Long was installed March 30, 1926 in Statuary Hall in the U. S. Capitol. Each state may have two statues in Statuary Hall, and Georgia’s other statue is of Alexander H. Stephens, Long’s former roommate at the University of Georgia who served as vice president of the Confederate States of America.</p><img src="https://counter.theconversation.com/content/113340/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Roger K. Thomas does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Most medical historians agree that one of the most important advances in medicine was the use of ether to numb pain during surgery. Just who deserves credit for this has been another story.Roger K. Thomas, Professor Emeritus, Behavioral Neuroscience, University of GeorgiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1136822019-03-21T13:05:32Z2019-03-21T13:05:32ZWhat African countries can do about ensuring safer surgery<figure><img src="https://images.theconversation.com/files/264581/original/file-20190319-60964-1543tdv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Tools like the WHO checklist can lead to better surgical outcomes in countries with limited resources.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The World Health Organisation (WHO) has come up with plans and tools to help countries ensure safer surgery in their hospitals and clinics. These include the <a href="https://www.who.int/patientsafety/safesurgery/checklist/en/">surgical safety checklist</a> and <a href="https://www.who.int/patientsafety/implementation/checklists/childbirth/en/">safe childbirth checklist</a>.</p>
<p>But implementation is still poor in most African countries.</p>
<p>A recent <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)60160-X.pdf">report</a> in The Lancet medical journal suggests that at least 4·2 million people worldwide die within 30 days of surgery each year. Half of these deaths occur in low- and middle-income countries. This number of postoperative deaths accounts for <a href="https://www.ncbi.nlm.nih.gov/pubmed/28919116?dopt=Abstract">7·7%</a> of all deaths globally, making it the third greatest <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)33139-8/fulltext#fig1">contributor to deaths</a>, after heart disease and stroke.</p>
<p>This might in fact be an underestimate as little is known about the quality of surgery globally. This is because robust reports of postoperative death rates are available for only <a href="http://docs.wixstatic.com/ugd/346076_c853bd6c09d34ed6bca4b9b622d69de3.pdf">29 countries</a>. </p>
<p>Surgery and anaesthesia have long been neglected in global health given the need to focus on communicable diseases. However, the 2016 World Health Assembly emphasised universal care for all, including strengthening of surgery and anaesthesia. Only <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(14)70349-3/fulltext">12%</a> of the specialist surgical workforce practice in Africa and Asia, where a third of the world’s population lives.</p>
<p>This inequality and the lack of access to safe surgical interventions in low and middle-income countries lead to unacceptably high rates of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6173895/">morbidity and mortality</a>. </p>
<p>During our <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4982013/">research</a> in East Africa we set out to determine the knowledge of anaesthetists and their attitudes towards the use of the WHO checklist for surgical patients in national referral hospitals. We found that only a quarter of the anaesthetists we interviewed at the main teaching and referral hospitals used the WHO’s Safe Surgical Checklist. Results from our research in Uganda paint a similarly dismal picture.</p>
<p>In separate research to access the pre and post operative care for mothers giving birth in Uganda, we <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6173895/">also found</a> that only 34% of the 64 hospitals we surveyed used the WHO safe surgical checklist. This study covered 100% of the government regional referral hospitals, 16% of government district hospitals and 33% of all private hospitals in Uganda. </p>
<p>Our results point to the need to implement essential tools like the WHO checklists. This is because they have been shown to lead to better surgical outcomes; and would possibly have more impact in countries facing challenges such as shortages of surgical specialists, drugs and equipment.</p>
<h2>What we found</h2>
<p>We conducted a survey from February 2013 to March 2014 in the main referral hospitals in hospitals in Uganda, Kenya, Tanzania, Rwanda and Burundi. During the survey we interviewed 85 anaesthetists working in the obstetric theatres in these national referral hospitals. We asked questions to determine their knowledge of the WHO Safe Surgical Checklist, and its availability and use at the various hospitals.</p>
<p>We found that only 25% of the anaesthetists regularly used the WHO safe surgical checklist. None of the anaesthetists in Mulago Hospital (Uganda) or Centre Hospitalo-Universitaire de Kamenge (Burundi) used the checklist, mainly because it was not available. </p>
<p>In Muhimbili Hospital in Tanzania only 65% of anaesthetists used the checklist. Only 19% in Kenyatta Hospital in Kenya and 36% in Centre Hospitalier Universitaire de Kigali in Rwanda used it.</p>
<p>None of the hospitals had anyone responsible for ensuring that the surgical checklist is available in each theatre, or checking that all members of the surgical team implement it. </p>
<p>Muhimbili Hospital in Tanzania had a locally designed pre-anaesthesia checklist for caesarean sections, which included machine, drugs and airway equipment checks. But 57% of the anaesthetists reported that it was not generally available for use.</p>
<h2>What needs to be done</h2>
<p>It’s necessary to make the WHO’s surgical checklist available, to train the surgical team on its importance and to identify local anaesthetists to champion its implementation in East Africa and other resource limited countries. </p>
<p>The ministries of health in the participating countries need to issue directives for the implementation of the WHO checklist in all hospitals that conduct surgery in order to improve surgical outcomes.</p><img src="https://counter.theconversation.com/content/113682/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Isabella Epiu received funding from USA National Institute of Health, World Federation of Societies of Anaesthesiologists, The World Bank, Government of Uganda</span></em></p>Research found that only a quarter of anaesthetists working in main referral hospitals in East Africa used the WHO safe surgical checklist.Isabella Epiu, MD PhD, Postdoctoral Fellow Global Health, University of California Global Health Institute (UCGHI), Makerere UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/958602018-06-19T04:44:15Z2018-06-19T04:44:15ZHow old is too old for surgery, and why?<figure><img src="https://images.theconversation.com/files/221699/original/file-20180605-175438-1003hmr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many changes in the body occur in response to the injury and trauma inflicted during surgery. </span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>Many of us will have been in situations with older loved ones where a doctor says surgery is too risky given the patient’s advanced age. Why is it surgery becomes risky in the elderly, and is it based on chronological age or their health?</p>
<p>During surgery and anaesthesia, there are many changes in the body that occur in response to injury and trauma. This is known as the stress response to surgery.</p>
<p>The surgical stress response results in an increased secretion of hormones that promote the break down of carbohydrates, fats and proteins in the body to provide extra energy during and after surgery. The hormonal changes associated with the surgical stress response also <a href="https://doi.org/10.1093/bja/85.1.109">activate the sympathetic nervous system</a>. </p>
<p>The sympathetic nervous system is responsible for the “fight or flight” response and causes a rise in heart rate and blood pressure. The changes in the heart rate and blood pressure during surgery and anaesthesia create a state where the heart requires more oxygen, while the surgical stress response and anaesthesia often impedes the oxygen supply to the vital organs such as the heart and the brain. This is a result of less blood flow to the body organs during and after the operation.</p>
<p>Anaesthesia confers risks separate from the risks of surgery. These are mostly minor and easy to treat. But serious problems with the heart, lungs and other major organs are more likely during emergency surgery or in the presence of other health conditions. These factors may increase with chronological age, but frailty is the bigger factor for doctors in deciding whether a patient should undergo surgery and anaesthesia.</p>
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<strong>
Read more:
<a href="https://theconversation.com/why-hip-fractures-in-the-elderly-are-often-a-death-sentence-95784">Why hip fractures in the elderly are often a death sentence</a>
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</em>
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<h2>Frailty</h2>
<p>Frailty is a state where a person is vulnerable due to decline in body function. This in turn reduces their ability to cope with acute and every day stressors.</p>
<p>In a frail person, there is an accumulation of defects in different organ systems of the body, causing them to function close to the threshold of failure. The organ systems near the threshold of failure are then <a href="https://doi.org/10.1093/qjmed/hcs125">unable to “bounce back”</a> from an external or internal stressor. </p>
<p>An apparently small insult such as a simple fall can result in a significant and disproportionate reduction in reserve and function. The need to have surgery, and the condition that has caused a need for surgery, would often be considered a large insult in a frail person.</p>
<p>Although frailty is more common in older people, it’s not exclusive to older people. Most frail people have chronic health problems, and their frailty increases with the number of chronic health conditions. But most people with chronic health conditions <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4369632/">are not frail</a>. </p>
<p>There are certain health conditions that are more common in people who are frail, such as heart failure, chronic airways disease and chronic kidney disease.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/surgery-isnt-always-the-best-option-and-the-decision-shouldnt-just-lie-with-the-doctor-64228">Surgery isn't always the best option, and the decision shouldn't just lie with the doctor</a>
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<h2>How do we identify frailty and how does it affect health?</h2>
<p>There are <a href="https://doi.org/10.1503/cmaj.050051">many different tools</a> we can use to detect frailty. The Clinical Frailty Scale is one tool based on clinical features present in the patient and the Frailty Index is another tool based on the accumulation of deficits in the patient. </p>
<p>The Clinical Frailty Scale is a single descriptor of a person’s level of frailty using clinical judgement graded from one to nine. Level one is a very fit person; level four is “vulnerable” – where the person is not dependent on others for help with daily activities but does have symptoms that limit activities; and level nine is a terminally ill person.</p>
<p>It has been observed that people with a higher Clinical Frailty Scale were more likely to be older, female, have a degree of cognitive impairment and incontinence. The higher proportion of females will most likely reflect the <a href="https://doi.org/10.1016/S0140-6736(12)62167-9">longer life expectancy of women</a>.</p>
<p>Frail people have a higher risk of recurrent falls and fractures and subsequent disability and reduced function. There have been <a href="https://dx.doi.org/10.1503%2Fcmaj.161403">many studies</a> performed to examine how well frailty predicts outcomes after surgery.</p>
<p>In people who have surgery, frailty has been shown to be associated with a higher risk of surgical complications, a greater chance of requiring discharge to a residential care facility and a lower rate of survival. And the more frail the patient, the higher the risk the patient will require readmission after surgery, and the higher the risk of death.</p>
<p>As our population gets older and more frail people have surgery, this will become an important issue, and health care professionals in all areas will need to be more aware of it.</p><img src="https://counter.theconversation.com/content/95860/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Juliana Kok does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Doctors may say you’re “too old” for surgery, but what they actually mean is too frail.Juliana Kok, Clinical Lecturer and anaesthetist, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/957192018-05-14T09:52:03Z2018-05-14T09:52:03ZThis is what really happens when you go under the knife<figure><img src="https://images.theconversation.com/files/218472/original/file-20180510-34038-y5mmtc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/medical-team-performing-surgical-operation-bright-741433855?src=-3BA1ZyV3GGvLHsWUU-S5A-1-28">shutterstock</a></span></figcaption></figure><p>We’ve all seen the TV dramas – <a href="http://abc.go.com/shows/greys-anatomy">Grey’s Anatomy</a>, <a href="https://www.imdb.com/title/tt0108757/">ER</a>, <a href="https://www.bbc.co.uk/programmes/b006m8wd">Casualty</a>, <a href="https://www.bbc.co.uk/programmes/b006mhd6">Holby City</a> – and most of us like to think we have a pretty good idea of what happens in an operating theatre. The doctors and nurses will be clad in blue scrubs, <a href="https://www.huffingtonpost.co.uk/entry/music-surgery_n_6310842">operatic music will be playing</a>, with intermittent calls of “scalpel” or “swabs”, right?</p>
<p>For those readers, who’ve ever had an operation – whether it was <a href="https://theconversation.com/seven-body-organs-you-can-live-without-84984">planned or an emergency</a> – things in the real world probably felt very different to those familiar TV drama medical emergency scenes. In part, this is because <a href="https://theconversation.com/greys-anatomy-is-unrealistic-but-it-might-make-junior-doctors-more-compassionate-92040">TV programmes often portray the staff</a> who work on the wards also working in the operating theatre – but this isn’t the case. </p>
<p>In fact, it’s not just doctors and nurses that make up part of the team involved in an operation, there is also a group of professionals, known as <a href="https://www.healthcareers.nhs.uk/explore-roles/allied-health-professionals/roles-allied-health-professions/operating-department-practitioner">operating department practitioners</a> (ODPs), who are trained specifically to look after you when you’re under the bright lights of the operating theatre. </p>
<h2>What happens when I arrive?</h2>
<p>Having an operation can be highly stressful. You might have been told not to eat before. It all feels a bit unknown, and you aren’t exactly sure what will happen. But the staff at the hospital are on hand to try and make things easy for you. </p>
<p>As you are arrive on the ward, a whole team of staff are busy preparing for your surgery. You’ll be asked to confirm who you are and what you’re being admitted for. You will also be asked to change into a very fetching hospital gown. Someone will also sit down and talk you through what’s happening and check you have not eaten – this is so you don’t vomit <a href="https://theconversation.com/science-lesson-how-anesthetics-work-and-why-xenons-perfect-83744">during your anaesthetic</a>. </p>
<h2>Who looks after me?</h2>
<p>The team looking after you has three sub teams working as one. They are the anaesthetic team, the surgical team and the post anaesthetic team. These teams work like cogs and your care and treatment is seamless. As a minimum, this would mean you would have nine health professionals caring for you at any one time. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/218471/original/file-20180510-34021-n03u0l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/218471/original/file-20180510-34021-n03u0l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=316&fit=crop&dpr=1 600w, https://images.theconversation.com/files/218471/original/file-20180510-34021-n03u0l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=316&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/218471/original/file-20180510-34021-n03u0l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=316&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/218471/original/file-20180510-34021-n03u0l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=398&fit=crop&dpr=1 754w, https://images.theconversation.com/files/218471/original/file-20180510-34021-n03u0l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=398&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/218471/original/file-20180510-34021-n03u0l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=398&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Knowing you’re in safe hands is important.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?u=http%3A%2F%2Fdownload.shutterstock.com%2Fgatekeeper%2FW3siZSI6MTUyNTk5MTk1OCwiYyI6Il9waG90b19zZXNzaW9uX2lkIiwiZGMiOiJpZGxfMjIxODgyODkwIiwiayI6InBob3RvLzIyMTg4Mjg5MC9odWdlLmpwZyIsIm0iOjEsImQiOiJzaHV0dGVyc3RvY2stbWVkaWEifSwiOEhvV2xNNVVYQW5XazNKcytkYkczVytlWlRzIl0%2Fshutterstock_221882890.jpg&ir=true&pi=11079995&m=221882890&src=lBmi03gtGnpC4nP43quMWQ-1-3">Shutterstock</a></span>
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<p>Your operating team on the day will have doctors – who are the anaesthetist, and the surgeon – but the rest of the team could be made up nurses, ODPs and healthcare assistants. ODPs are generally a graduate professional and they train through university in partnership with the hospital operating theatres.</p>
<h2>When do I have the anaesthetic?</h2>
<p>When the team is ready and it’s time for your surgery, you have your anaesthetic. This will be delivered by an anaesthetist, but there always has to be trained assistance – normally an ODP.</p>
<p>On arrival in the <a href="https://theconversation.com/scientists-find-way-to-predict-who-is-likely-to-wake-up-during-surgery-53217">anaesthetic room</a>, it is the ODP that greets you with a big smile and often a cheesy joke. After all, they have minutes to get to know you and for you to trust them with your life. They will attach you to the monitoring equipment and measure your baseline pulse and blood pressure readings. </p>
<p>You will need a cannula (a plastic tube) inserting into a vein, so the anaesthetist can give you the drugs. This is the point where you may be asked to start counting back slowly from ten – you won’t even get to seven.</p>
<h2>What happens during surgery?</h2>
<p>While the anaesthetic team continue to look after you, the surgical team carry out your operation. The surgeon will have at least one assistant – I have known more than ten people to be part of this team for major head and neck cancer surgery. The first assistant and other assistants scrub up with the surgeon and help with the surgery. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/218485/original/file-20180510-5968-1gco6wx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/218485/original/file-20180510-5968-1gco6wx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/218485/original/file-20180510-5968-1gco6wx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/218485/original/file-20180510-5968-1gco6wx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/218485/original/file-20180510-5968-1gco6wx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/218485/original/file-20180510-5968-1gco6wx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/218485/original/file-20180510-5968-1gco6wx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Laser-like precision.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/search?searchterm=black+hospital+patient+smiling&search_source=base_search_form&language=en&page=1&sort=popular&image_type=all&measurement=px&safe=true">Shutterstock</a></span>
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<p>Adding to this team there is a scrub practitioner and their role is to provide the swabs, needles and equipment to the surgeon and the assistants. They are the ones who also count everything to make sure you don’t leave the operating theatre with any unwanted extras. </p>
<h2>When can I go home?</h2>
<p>Once your <a href="https://theconversation.com/will-you-feel-better-after-surgery-now-you-can-find-out-using-this-online-tool-72758">surgery is complete</a> your wounds will be dressed by the surgical team. Your anaesthetic will be reversed and you will be taken to the post anaesthetic care unit – which used to be called recovery. Here you will be looked after until you are ready to be discharged back to the ward. Here, you wounds will be inspected, and whoever’s looking after you will make sure your <a href="https://theconversation.com/anthill-19-pain-87538">pain is under control</a> and you are not feeling sick. </p>
<p>Once you are awake and comfy, you will be taken back to the ward where your relatives may be waiting and you should be able to have something to eat and drink. Depending on your surgery and who you have at home to look after you, you may even be allowed to go home the same day.</p>
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<strong>
Read more:
<a href="https://theconversation.com/health-check-why-can-you-feel-groggy-days-after-an-operation-74989">Health Check: why can you feel groggy days after an operation?</a>
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<p class="fine-print"><em><span>Deborah Robinson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>What to expect when you’re expecting an operation.Deborah Robinson, Senior Lecturer and Head of Health and Social Work School, University of HullLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/837132017-09-11T07:06:20Z2017-09-11T07:06:20ZWe need to close legal loopholes to ensure everyone is safe when going under anaesthesia<figure><img src="https://images.theconversation.com/files/185401/original/file-20170911-9437-hvf4cm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">We shouldn't have to wait for a disaster to make sure anaesthetics are properly regulated. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>A young woman <a href="http://www.abc.net.au/news/2017-09-02/review-announced-after-botched-breast-surgery-death/8866152">tragically died recently</a> after a cosmetic operation carried out at a beauty clinic. Manslaughter charges have been brought against the practitioner, who allegedly has qualifications obtained overseas but was not registered to practise in Australia. </p>
<p>The Australian and New Zealand College of Anaesthetists, the Royal Australian College of Surgeons and state ministers <a href="http://www.news.com.au/national/breaking-news/doctors-seek-changes-after-salon-death/news-story/93c0d08c878a8e5d3a7835819cd3efee">are examining the regulations</a> around who can deliver sedation and general anaesthesia, and the licensing of using high dose local anaesthesia.</p>
<h2>Who can legally deliver anaesthetics?</h2>
<p>The Australian and New Zealand College of Anaesthetists is the body responsible for the teaching, training and licensing of specialist anaesthetists who are referred to as “fellows”. Specialist anaesthetists have a medical degree, and undergo extensive further training to be qualified to administer anaesthetics.</p>
<p>For many doctors, certification as a specialist anaesthetist is the culmination of more than a decade of examination, full-time training and dedication to the safe practice of anaesthesia and sedation. Specialist anaesthetists practise in many different environments, and not just the operating theatre.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/a-short-history-of-anaesthesia-from-unspeakable-agony-to-unlocking-consciousness-74748">A short history of anaesthesia: from unspeakable agony to unlocking consciousness</a>
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<p>GPs can also receive special training to administer anaesthesia to low risk patients in remote and rural areas, a vital service.</p>
<p>Sedation and local anaesthesia are also frequently used in emergency departments and intensive care units, delivered by doctors who are specialists in areas such as emergency or intensive care medicine. They are trained in anaesthesia with skill sets in airway management and resuscitation. These doctors work in safe environments, and in highly trained teams of nurses and other health professionals.</p>
<p>The <a href="http://www.anzca.edu.au/resources/professional-documents">Australian and New Zealand College of Anaesthetists</a> has several guidelines, specifying a <a href="http://www.medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-conduct.aspx">code of conduct</a>. These include the responsibilities and skills necessary for a medical practitioner to give sedation, criteria for the location in which the anaesthesia is to be administered, patient selection, drug selection, and availability of emergency equipment. These are endorsed by multiple other professional bodies and colleges.</p>
<p>The <a href="https://www.scientificamerican.com/article/propofol-michael-jackson-doctor/">death of Michael Jackson</a> and the <a href="http://www.nbcbayarea.com/news/local/Dental-Anesthesia-Under-Scrutiny-After-Child-Dies-381594491.html">death of a child in California</a> highlight the risks of untrained practitioners administering anaesthetic drugs.</p>
<p>The practitioner in the recent case in Australia was allegedly practising contrary to state regulations, with credentials not recognised in Australia. This <a href="http://www.sbs.com.au/yourlanguage/mandarin/en/article/2017/09/01/beauty-industry-chaotic-and-out-control-woman-dies-following-breast-surgery">may not be uncommon</a>, and is challenging to regulate until disaster occurs.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/185404/original/file-20170911-9453-frfj6r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/185404/original/file-20170911-9453-frfj6r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/185404/original/file-20170911-9453-frfj6r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=337&fit=crop&dpr=1 600w, https://images.theconversation.com/files/185404/original/file-20170911-9453-frfj6r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=337&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/185404/original/file-20170911-9453-frfj6r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=337&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/185404/original/file-20170911-9453-frfj6r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/185404/original/file-20170911-9453-frfj6r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/185404/original/file-20170911-9453-frfj6r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Anyone administering anaesthesia of any kind needs to know how to resuscitate patients in case of emergency.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
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</figure>
<h2>How do these disasters occur?</h2>
<p>General anaesthesia and sedation are very safe in Australia when the drugs are administered by doctors with training in pharmacology, airway management and resuscitation. But <a href="http://www.smh.com.au/nsw/unregulated-conscious-sedation-for-cosmetic-surgery-is-putting-lives-at-risk-doctors-warn-20150714-gibp5j.html">there are gaps in the regulation</a>, particularly around “sedation” and local anaesthesia, <a href="http://www.abc.net.au/news/2016-04-20/tci-report-prompts-call-for-national-cosmetic-surgery-laws/7339538">which have been under scrutiny by some groups</a> for some time.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/anaesthesia-the-gift-of-oblivion-and-the-mystery-of-consciousness-book-review-81022">Anaesthesia: the gift of oblivion and the mystery of consciousness – book review</a>
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<p>Dentistry and cosmetic surgery are two areas that may be vulnerable to these loopholes. The Australian Health Practitioners Regulation Agency has a <a href="http://www.dentalboard.gov.au/documents/default.aspx?record=WD15%2f18393&dbid=AP&chksum=UuikUcCKpqOJE%2fgp40FdLQ%3d%3d">guide for dentists</a> on administration of intravenous sedation. This is when a drug, usually an anti-anxiety drug, is administered for a dental procedure where the patient stays awake. </p>
<p>The document excludes general anaethesia as dentists are not expected to put patients to sleep during procedures. For intravenous anaesthesia they must have another health-care practitioner present, who may be a nurse. Regulations and licensing of sites varies from state to state, and patient selection and drug dosage are key features of safe practice of this type of sedation.</p>
<p>The regulators of dental sedation and beauty clinics haven’t endorsed the Australian and New Zealand College of Anaesthetists’s guidelines, meaning there are loopholes that can be exploited by dodgy practitioners. </p>
<p>This means a lot of things can happen that are outside the margins of safety, but may not come to light until there is a disaster. Because these loopholes exist in the law, what these practitioners are doing may not be illegal, although unsafe. </p>
<p>There’s a fine balance, which varies greatly between patients, in the margin of safety and effectiveness for the drugs we use to sedate and desensitise patients. Loss of consciousness, and therefore loss of protective reflexes, <a href="https://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwisn6aKhJzWAhWBvpQKHTlqAg4QFggoMAA&url=http%3A%2F%2Fwww.anzca.edu.au%2Fdocuments%2Fps09-2014-guidelines-on-sedation-and-or-analgesia&usg=AFQjCNGexwJNczDHwIfbX5E31Q5GXes40A">can occur rapidly and unexpectedly</a>. This takes many years of training and experience to get right.</p>
<p>Cosmetic surgery is currently under fierce debate in Australia as it falls outside the regulations of the college of surgeons. As the recent case highlights, there are practitioners who are not following the codes of conduct proposed by the regulatory bodies.</p>
<p>This is complicated by a lack of availability (or possibly feasibility) of “appropriate training” outside what is offered by the college of anaesthetists, and the somewhat unpredictable nature of the drugs, especially in inexperienced hands.</p>
<h2>How can you be sure you’re in safe hands when going under?</h2>
<p>Professor David A. Scott, <a href="http://www.anzca.edu.au/communications/media/media-releases-2017-(1)/obese-and-elderly-should-quiz-doctors-about-surgery">the current president of the college of anaesthetists</a> recommends patients choose the location of their surgery wisely - particularly if you’re elderly or have other disease. </p>
<p>Ask the doctor administering the sedation if they have the necessary qualifications and training to do so - and check if they’re on <a href="http://www.ahpra.gov.au/registration/registers-of-practitioners.aspx">Australia’s list of medical practitioners</a> overseen by the <a href="https://www.ahpra.gov.au/">Australian Health Practitioner Regulation Agency</a>. </p>
<p>And we should all make some noise to make sure the government enshrines these regulations in legislation. Until then there will be loopholes for unscrupulous practitioners to use to circumvent the guidelines, compromising safety.</p><img src="https://counter.theconversation.com/content/83713/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kara Allen is a specialist anaesthetist and a Fellow of the Australian and New Zealand College of Anaesthetists.</span></em></p>After the tragic death of a young woman undergoing a cosmetic procedure, people are rightly asking who should be able to administer anaesthetics.Kara Allen, Clinical Lecturer, Anaesthetist, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/837442017-09-10T23:12:11Z2017-09-10T23:12:11ZScience lesson: How anesthetics work, and why xenon’s perfect<figure><img src="https://images.theconversation.com/files/185278/original/file-20170908-32313-1n0er7e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">General anesthetics affect cellular proteins to knock us out. Some do so better than others, especially the noble gas Xenon. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Common wisdom maintains that, because of the myriad effects on the brain, how anesthetic drugs work at the molecular level <a href="http://io9.gizmodo.com/how-does-anesthesia-work-doctors-arent-sure-and-her-1592809615">is a mystery.</a></p>
<p>On the contrary. As a longtime pharmacology researcher, I believe there’s a sufficient body of evidence to certify it’s not so mysterious after all.</p>
<p>First, some information —and a bit of a history lesson — on anesthetics for all the armchair scientists and doctors among us.</p>
<p>General anesthetics are so called because the administered drug is transported via the blood throughout the body, including the brain — the intended target.</p>
<p>The first general anesthetic used clinically was <a href="https://eic.rsc.org/feature/nitrous-oxide-are-you-having-a-laugh/2020202.article">nitrous oxide,</a> a gas synthesized in a research lab in 1772. It’s still known as laughing gas, and in later years, because it could not silence the brain sufficiently, it was useful only for minor surgery.</p>
<p>By the 1800s, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1279690/">William T.G. Morton</a> (1819-1868), a young Boston dentist, was on the hunt for a better anesthetic than nitrous oxide, commonly used then by dentists. </p>
<p>Ether was a liquid compound produced by distilling ethanol and sulfuric acid. It was just a curiosity at the time. But Morton left a bottle of ether open in his living room and passed out. In 1846, he gave the first public demonstration of ether’s effects on a patient undergoing major surgery.</p>
<h2>How it works</h2>
<p>How do general anesthetics like ether work to subdue brain function?</p>
<p>Most are inhaled and administered from pressure tanks. Ether, as a liquid, emits vapours that are inhaled. Another extremely potent liquid anesthetic is propofol, administered intravenously. It was identified <a href="http://www.telegraph.co.uk/culture/music/michael-jackson/10272782/Michael-Jackson-sought-propofol-long-before-death-says-doctor.html">as a major contributor</a> to pop icon Michael Jackson’s death. </p>
<p>Some barbiturates given via IV are useful general anesthetics. Alcohol is another, but it’s too toxic for clinical use.</p>
<p>The process of anesthesia is commonly divided into four stages. </p>
<h2>The four phases of unconsciousness</h2>
<p>Stage 1 is known as induction, the period between the administration of anesthetic and loss of consciousness. </p>
<p>Stage 2 is the excitement stage, the period following loss of consciousness and marked by excited and delirious activity.</p>
<p>Stage 3 is surgical anesthesia. Skeletal muscles relax, vomiting stops if present, respiratory depression and eye movements stop. The patient is ready for surgery. </p>
<p>Stage 4 is overdose, involving severe depression of vital organs that can be lethal. </p>
<h2>Works in worms like it works in humans</h2>
<p>The various compounds that produce anesthesia in human beings do so in all animals, including invertebrates. The response of the earthworm, C. elegans, to the steady administration of anesthetic elicits a progressive depression of function similar to how it works in humans. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/185346/original/file-20170909-32313-xxqknn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/185346/original/file-20170909-32313-xxqknn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=376&fit=crop&dpr=1 600w, https://images.theconversation.com/files/185346/original/file-20170909-32313-xxqknn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=376&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/185346/original/file-20170909-32313-xxqknn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=376&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/185346/original/file-20170909-32313-xxqknn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=473&fit=crop&dpr=1 754w, https://images.theconversation.com/files/185346/original/file-20170909-32313-xxqknn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=473&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/185346/original/file-20170909-32313-xxqknn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=473&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Earthworms respond just as humans do to anesthetic, becoming slow and uncoordinated before finally passing out.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>There is an initial phase of increased locomotion, followed by uncoordination, and finally immobility. Motion returns quickly when the administration of the anesthetic stops. This shows that optimal nerve cell architecture developed early in the evolution of life on Earth.</p>
<p>But now let’s do a deep dive into what happens at the molecular level. How does the anesthetic molecule obstruct vital molecules or molecule assemblies essential for cell function in order to bring about unconsciousness?</p>
<p>A prevalent <a href="https://paulingblog.wordpress.com/2009/06/04/the-meyer-overton-theory-of-anesthesia/">lipid (fat) theory of anesthetic action</a> had been based on the fact that all anesthetics are “hydrophobic” chemical compounds, meaning they mix with oil but not water. Presumably, they impair brain cell (neuron) function and bring about unconsciousness by dissolving into the fatty cell membranes, thereby disrupting normal cell activity.</p>
<p>I doubted this theory.</p>
<h2>Proteins are critical to understanding anesthesia</h2>
<p>And so 35 years ago, I made the observation that the molecular weights of the different anesthetics were no more than about 350 <a href="https://sizes.com/units/dalton.htm">Daltons,</a> comparable in size to the smaller messenger molecules that activate the utilitarian proteins in cells. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/185345/original/file-20170909-27562-3artt6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/185345/original/file-20170909-27562-3artt6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=350&fit=crop&dpr=1 600w, https://images.theconversation.com/files/185345/original/file-20170909-27562-3artt6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=350&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/185345/original/file-20170909-27562-3artt6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=350&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/185345/original/file-20170909-27562-3artt6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=440&fit=crop&dpr=1 754w, https://images.theconversation.com/files/185345/original/file-20170909-27562-3artt6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=440&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/185345/original/file-20170909-27562-3artt6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=440&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">An artist’s rendering of human cells. Anesthetics do their work when their molecules penetrate the cavity in a cell’s protein, which in turn sets off a neural process that results in sedation.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Functional, vital proteins are the cell’s workhorses. They include receptors that serve to communicate to the cell signals from hormones and other regulators that induce changes in cell activity in a variety of ways, and ion channels that constantly monitor and control the cells’ levels of sodium, potassium and calcium, a process particularly vital for brain cell function.</p>
<p>The proteins are spherical and contain at their cores a cavity lined with hydrophobic parts (those that mix with oil, not water) of the surrounding <a href="http://study.com/academy/lesson/what-are-amino-acids-definition-structure-quiz.html">constituent amino acids</a>, and they accommodate small <a href="https://www.neurogistics.com/the-science/what-are-neurotransmitters">so-called regulator molecules.</a></p>
<p>The cavities are about the same size for all these proteins, but differ from one another only by the types of constituent amino acids both lining and around the cavity.</p>
<h2>Cavity penetration sets off chain of events</h2>
<p>An estimated volume for the cavity reported for one particular type of protein ranged from 853 to 1,566 cubic <a href="http://whatis.techtarget.com/definition/angstrom-angstrom-unit">Angstroms.</a> By way of comparison, the volume of an occupant of the cavity, the epilepsy drug diphenylhydantoin (brand name Dilantin, used to control seizures) was reported as 693 cubic Angstroms — small enough to occupy the cavity, as all anesthetics are.</p>
<p>The penetration into the cavity by the regulator molecule causes the protein to activate an intracellular process, or the opening of an ion channel that, as mentioned, controls the brain cell’s levels of sodium, potassium and calcium. The anesthetic molecule displaces the regulator, normal cell activity ceases and unconsciousness results.</p>
<p><em>Is There a General Anesthesia Receptor?</em> That’s the title of <a href="https://www.ncbi.nlm.nih.gov/pubmed/6263435">a paper I published in 1982.</a> The answer is: Yes, there is a general anesthesia receptor. It’s the crucial central cavity in all vital cell proteins. </p>
<p>The many cellular vital proteins and their small regulator molecules constitute a biological lock-and-key, each lock with its own special key. The anesthetic molecule occupies all locks, thereby obstructing all keys. </p>
<p>Today, it’s generally accepted that proteins are the targets of general anesthetics and that the lipid theory is ancient history.</p>
<h2>So what’s the perfect anesthetic?</h2>
<p>The diverse molecular structures of anesthetics are reflected in their different repertoires of interactions with numerous protein cavities and other cellular entities. That means each anesthetic is unique in how it precisely sedates patients, and has unique side effects.</p>
<p>The ideal anesthetic would have these major characteristics: chemical stability, low flammability, lack of irritation to airway passages, low blood:gas solubility to allow for patients to be sedated and brought out of sedation quickly, minimal cardiovascular and respiratory side effects, minimal effect on brain blood flow and low interactions with other administered drugs.</p>
<p>In the operating room, the agent that ticks all those boxes is the gaseous xenon atom.</p>
<p>Xenon is one of the mono-atomic rare, “noble” gases present in trace amounts in the atmosphere. The others are helium, neon, argon, krypton and radon. They are inert, meaning they have extremely low chemical reactivity.</p>
<p>Xenon’s sole interaction with biological tissue is the occupation of protein cavities. </p>
<p>The xenon atom is like a smooth, round billiard ball and has no exchangeable electrons and no appendages, i.e. additional atoms, to engage other cellular entities. In contrast, other anesthetics are comprised of multiple atoms, all of which express reactive electrons, a feature that accounts for many of their side effects. The xenon atom literally just rolls into a protein.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/185382/original/file-20170910-32284-f12igi.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/185382/original/file-20170910-32284-f12igi.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=480&fit=crop&dpr=1 600w, https://images.theconversation.com/files/185382/original/file-20170910-32284-f12igi.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=480&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/185382/original/file-20170910-32284-f12igi.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=480&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/185382/original/file-20170910-32284-f12igi.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=604&fit=crop&dpr=1 754w, https://images.theconversation.com/files/185382/original/file-20170910-32284-f12igi.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=604&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/185382/original/file-20170910-32284-f12igi.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=604&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The structure of a brain neuron. Anesthetics diffuse into the cell body to inhibit vital proteins, thereby silencing both the transmitting and receiving neurons.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The gas is unique. Side effects are almost non-existent. </p>
<p>Inhaled, blood-borne xenon permeates body tissues harmlessly until it engages a protein pocket, where it becomes entrapped. The amino acids lining the cavity then form a tight bond with xenon.</p>
<h2>Xenon: A noble gas, a noble anesthetic</h2>
<p>As a result, xenon shuts out the physiological activator molecule, leading to the shutdown of the vital protein and, thus, impairment of cell function. All of that amounts to a safely and efficiently unconscious patient.</p>
<p>So why isn’t xenon the anesthetic of choice for surgery in general? </p>
<p>A chief factor is <a href="https://www.ncbi.nlm.nih.gov/pubmed/10526826">its steep pricetag.</a> There have been attempts to overcome that hurdle by, for example, installing devices to recover the exhaled xenon in the operating room atmosphere after it’s been administered to a patient; xenon recycling, so to speak. </p>
<p>That’s a challenge. The next formidable challenge in our understanding of anesthetics is figuring out which vital proteins in which brain neurons — among the billions of neurons — are silenced in turn with progressively deeper anesthesia. </p>
<p>But, optimistically, that can be the subject of a future science lesson.</p><img src="https://counter.theconversation.com/content/83744/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Frank LaBella during his career has received research funds and salary support from several government and public granting bodies.</span></em></p>How do anesthetics work, and what makes for an ideal anesthetic? It’s not as mysterious as once believed, and there’s a gas that ticks all the boxes for a perfect anesthetic: xenon.Frank LaBella, Professor Emeritus, Department of Pharmacology and Therapeutics, University of ManitobaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/810222017-07-26T01:54:36Z2017-07-26T01:54:36ZAnaesthesia: the gift of oblivion and the mystery of consciousness – book review<figure><img src="https://images.theconversation.com/files/178955/original/file-20170720-23989-1de877o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A new book explores consciousness, awareness and memory when under the knife. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>The French refer to the emergence from general anaesthesia as “réanimation” - literally to restore consciousness. This is a crucial attribute - that consciousness will return following the desired period of oblivion. This is skilfully explored in Kate Cole-Adams’ book Anaesthesia.</p>
<p>Cole-Adams delves into questions about consciousness and self. Are we restored fully to self or does the experience of anaesthesia change us in a way that may not be measurable? The result is a nuanced, powerful book, grounded in Cole-Adams’ decision to undergo scoliosis surgery, and developed around the analogy of submerging in a bottomless sea and breaking into wakefulness like a swimmer surfacing from the depths.</p>
<p>Anaesthetists have a short time to establish rapport with a patient who is quite literally putting their life in our hands. We know our purpose is to provide unconsciousness and analgesia, so short-term harm can take place for long-term gain. Cole-Adams writes eloquently:</p>
<blockquote>
<p>It is a form of denial that enables them to act upon us in ways that would otherwise be unthinkable. To ignore the ghostly griefs and joys and hopes that trail each of us into the operating rooms, and to get on with the vital business of slicing, splicing and excision.</p>
</blockquote>
<p>Occasionally the book strays into the sensational, particularly with reference to studies investigating situations where people have become aware while under anaesthesia, but don’t have a memory of this happening. But predominantly, Cole-Adams writes compassionately and competently about the art and science of anaesthesia, and of practitioner and patient.</p>
<p>As a practitioner, it’s fascinating and beautifully written. Some 50% of the population of Australia and New Zealand are <a href="http://www.anzca.edu.au/communications/2013-national-anaesthesia-day">not sure that anaesthetists are doctors</a>, so a book that outlines the contribution of a specialist anaesthetist is very welcome.</p>
<p>Much of Cole-Adams’ focus is on two of the biggest aims of anaethesia: rendering the person unaware of what is happening, and ensuring they don’t remember it later. She also explores the complex question of consciousness - if we don’t form memories of an experience, and have no detectable conscious perception at the time, does the experience cause us harm?</p>
<h2>Awareness and recall under the knife</h2>
<p>Cole-Adams explores the phenomenon where people become aware during surgery, and can remember it. This is known as “awareness with recall”. There’s no doubt awareness with recall is an important problem with profound implications for the patient. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/178956/original/file-20170720-24026-1v8tovm.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/178956/original/file-20170720-24026-1v8tovm.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/178956/original/file-20170720-24026-1v8tovm.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=914&fit=crop&dpr=1 600w, https://images.theconversation.com/files/178956/original/file-20170720-24026-1v8tovm.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=914&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/178956/original/file-20170720-24026-1v8tovm.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=914&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/178956/original/file-20170720-24026-1v8tovm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1149&fit=crop&dpr=1 754w, https://images.theconversation.com/files/178956/original/file-20170720-24026-1v8tovm.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1149&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/178956/original/file-20170720-24026-1v8tovm.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1149&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Anaesthesia by Kate Cole Adams.</span>
</figcaption>
</figure>
<p>A <a href="http://nap5.org.uk/NAP5report">large study</a> found the number of patients aware during surgery was extremely low (measured by validated questionnaires administered after the operation), although some procedures (such as those with very large volumes of blood lost) and patients (such as those with severe heart or lung disease) were at higher risk than others. </p>
<p>Most cases were brief and not associated with distress or pain. Compassionate, timely disclosure of the events leading to the awareness and psychological support decreased long-term implications such as post-traumatic stress disorder, which could otherwise be severe.</p>
<p>She examines several “spooky little studies” that found people were aware under anaesthetic, but spends less time on the <a href="https://www.ncbi.nlm.nih.gov/pubmed/9165967">studies that failed to find</a> evidence these things occur. The popular press like to focus on graphic and shocking stories, but it’s important to remember these are rare and extreme cases.</p>
<p>She also explores “<a href="https://www.ncbi.nlm.nih.gov/pubmed/4061894">perception under anaesthesia</a>” - where a person may show a preference for certain words or images they heard or saw under anaesthesia. <a href="http://nap5.org.uk/NAP5report">Studies have shown</a> the overwhelming majority of patients have no detectable memories or evidence of consciousness under general anaesthesia.</p>
<p>And does it matter if someone perceives they’re in surgery while under anaesthetic if they don’t remember it afterwards? We don’t have enough information to say perception while undergoing surgery won’t affect someone psychologically if they don’t remember it. The process of surgery and post-operative recovery can all take a psychological and physical toll. It’s an interesting question, but almost impossible to answer. </p>
<p>Awareness is a rare but real problem that should be examined, whereas we’re not really sure perception under anaesthesia exists. And if it does, we don’t know if it would affect the patient at all since they have no memory of it.</p>
<h2>Consciousness</h2>
<p>Consciousness is a continuum - from drowsy through to completely inert. In situations where sedation is required, anaesthetists will administer drugs to cause amnesia, reduce pain and occasionally cause brief periods of unconsciousness. There are no hard and fast barriers between sedation and general anaesthesia - “deep sedation” often looks very much like general anaesthetic. </p>
<p>As consciousness recedes, harm to heart and lung function are more likely. This is particularly concerning when sedation is administered by health professionals <a href="https://academic.oup.com/bja/article/111/2/136/254462/II-Is-sedation-by-non-anaesthetists-really-safe">without specialty training or indeed medical training</a>. Only the term “specialist anaesthestist” is protected, so a less qualified person may administer anaesthesia or sedation, for example by the proceduralist in cosmetic surgery or dentistry. It’s one thing to put a patient to sleep; it may be a more difficult task to wake them up again.</p>
<p>This is fundamentally a story, not a scientific text, and has the potential to be slightly alarming for the uninitiated. We are fortunate in Australia that anaesthesia is extremely safe and highly reliable, but often there is emphasis on complications in the media. Cole-Adams has thought deeply about these topics, resulting in a book that is an exploration of the psychological, physiological and at times philosophical roles of anaesthesia and the implications for modern surgery. </p>
<p>For the interested reader, it’s an outline of the science, with an emphasis on the unknown. For the practitioner, it’s a patient experience, eloquently expressed. There’s much more to anaesthesia than meets the eye, and this book provides a glimpse into the depths.</p><img src="https://counter.theconversation.com/content/81022/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kara Allen does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Author Kate Cole-Adams delves into fascinating questions about consciousness and self.Kara Allen, Clinical Lecturer, Anaesthetist, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/749892017-05-18T01:58:35Z2017-05-18T01:58:35ZHealth Check: why can you feel groggy days after an operation?<figure><img src="https://images.theconversation.com/files/164025/original/image-20170405-5739-1u2blpf.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Feeling tired or being unable to concentrate is common even days after surgery. But there are simple ways to help speed up your recovery. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/jjay69/5913824188/">Jason Jones/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>You have a small operation under general anaesthesia and go home the same day. Two days later you’re back at work, but you can’t concentrate and have a desperate desire to take a nap. Why does this happen and how can you prevent it?</p>
<p><a href="http://www.anzca.edu.au/patients/what-is-anaesthesia">General anaesthesia</a> is a reversible drug-induced coma, during which you are unconscious, don’t feel pain and don’t remember anything. This is precisely what you want when you’re having an invasive or painful procedure. </p>
<p>However, some people suffer <a href="http://onlinelibrary.wiley.com/doi/10.1111/aas.12381/full">lingering effects</a> in the days after anaesthesia. These include drowsiness, slowed reaction times, and difficulty concentrating, remembering new information and finishing complex tasks.</p>
<p>Thankfully, these unwanted effects usually wear off by the next day, but sometimes they last for a <a href="http://www.sciencedirect.com/science/article/pii/S0022399903006159">few more days or even weeks</a>. Then they can really disrupt your ability to work or get anything done at home.</p>
<h2>It’s easy to blame the anaesthetics</h2>
<p>The effects of general anaesthesia may appear to linger for days after surgery for many reasons. Tiredness after a procedure is commonly attributed to anaesthetics. But modern anaesthetics wear off completely in a <a href="https://www.ncbi.nlm.nih.gov/pubmed/10624999">couple of hours</a>, so the real picture is usually more complicated. </p>
<p>The surgical condition for which you had the procedure may have stopped you leading a full and active life for some time, resulting in lack of fitness and less reserve for recovery.</p>
<p>The surgery itself causes tissue injury. After surgery, your body undergoes repair and recovery, which drives a higher baseline metabolic rate and draws on your nutrient stores. So it isn’t surprising such intense activity at a cellular level results in feeling tired after surgery. </p>
<p>If you ignored your doctor’s advice to take it easy before or after surgery, that could also explain why you’re feeling tired.</p>
<p>Then there’s pain treatment <a href="http://fpm.anzca.edu.au/documents/apmse4_2015_final">before and after the procedure</a>, which can also contribute to grogginess.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/165413/original/image-20170415-25865-1h0f7fo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/165413/original/image-20170415-25865-1h0f7fo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=539&fit=crop&dpr=1 600w, https://images.theconversation.com/files/165413/original/image-20170415-25865-1h0f7fo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=539&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/165413/original/image-20170415-25865-1h0f7fo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=539&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/165413/original/image-20170415-25865-1h0f7fo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=677&fit=crop&dpr=1 754w, https://images.theconversation.com/files/165413/original/image-20170415-25865-1h0f7fo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=677&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/165413/original/image-20170415-25865-1h0f7fo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=677&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Strong painkillers you take before or after surgery, like oxycodone, can also make you feel drowsy. But side effects cease once you stop taking them.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/554771338?src=LN8q-gZZ5jerIDiN9S-odQ-1-4&size=medium_jpg">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>For instance, opioids (such as oxycodone) and gabapentinoids (such as pregabalin) are strong pain medicines often prescribed after surgery. They are important in ensuring a comfortable recovery and rapid return to normal life, but may result in grogginess and confusion, especially in higher doses. </p>
<p>Opioids are usually needed <a href="https://www2.health.vic.gov.au/hospitals-and-health-services/quality-safety-service/quality-use-of-medicines/opioid-risk-reduction">for only a few days after surgery</a> and these side effects stop when you stop taking them.</p>
<p>Finally, general anaesthetics <a href="https://academic.oup.com/bja/article/109/5/769/305281/Sleep-disturbances-after-fast-track-hip-and-knee">interfere with your body clock</a>. This <a href="http://www.tandfonline.com/doi/abs/10.1080/07420528.2016.1208664">could be</a> because
anaesthetics <a href="https://www.ncbi.nlm.nih.gov/pubmed/24498074">interfere</a>
with brain hormones, such as melatonin, and messenger chemicals called neurotransmitters.</p>
<p>While <a href="https://nutritionj.biomedcentral.com/articles/10.1186/1475-2891-13-106">melatonin tablets can treat jet lag</a>, which is also a disruption of the body clock, there is no good evidence to use melatonin for anaesthesia-induced body-clock disruption in humans.</p>
<h2>Can you prevent grogginess?</h2>
<p>An operation is a major life event. Make sure you get adequate rest and have enough support at work and home before your surgery.</p>
<p>A bit of anxiety is normal before surgery and can also be exhausting. You can reduce your anxiety by asking for clear explanations of what to expect, and by maintaining a warm, comfortable and calm waiting environment.</p>
<p>If you are very anxious, your <a href="http://www.anzca.edu.au/documents/what-is-an-anaesthetist.pdf">anaesthetist</a> can give you a sedative “pre-med” before you go to theatre. But the use of sedatives is a balancing act, as the calming effect before the procedure is desirable but not the “hangover” drowsiness afterwards, which may last for several hours.</p>
<p>Your anaesthetist is the medically trained specialist who can not only give you a “pre-med” but will look after you during your operation and plan your recovery. He or she will develop an individualised anaesthetic plan based on short-acting anaesthetics and a combination of pain-killings drugs.</p>
<p>Your anaesthetist will also advise you how to best control your pain after surgery and when you return home. This will often involve using simple pain medicines, such as paracetamol and anti-inflammatory drugs, as well as opioids, which you will need to treat strong pain. Using simple pain medicines will help to reduce the doses of opioids that you need, and help you to avoid the nausea, constipation and grogginess that goes with them.</p>
<h2>Get back into good sleep habits</h2>
<p>After a procedure, you can combat the disruption to your body clock by practising good <a href="https://sleepfoundation.org/sleep-topics/sleep-hygiene">“sleep hygiene”</a>. This involves <a href="https://theconversation.com/health-check-five-ways-to-get-a-better-nights-sleep-43700">maximising cues</a> to the body that it is time to sleep in the evening. These could include avoiding stimulants like caffeine and alcohol, going to bed at a similar time each night, being in a <a href="https://theconversation.com/a-dark-night-is-good-for-your-health-39161">dimly lit room</a> and engaging in calming or restful activities before sleep, like reading.</p>
<p>Making sure you are exposed to bright sunshine during the day and <a href="https://theconversation.com/booting-up-or-powering-down-how-e-readers-affect-your-sleep-36145">avoiding back-lit screens</a> on technology devices in the evening can also help.</p>
<p>Lingering grogginess after general anaesthesia is hardly ever sinister. But if it is persistent, getting worse rather than better, or is associated with confusion, weakness or numbness, then you must see your doctor.</p><img src="https://counter.theconversation.com/content/74989/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Some people can feel drowsy or can’t concentrate days after an operation. While it’s easy to blame the anaesthetics, the real picture is usually more complicated.Kate Leslie, Honorary professorial fellow, Department of Pharmacology, The University of MelbourneMegan Allen, Honorary Fellow, Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/747482017-05-01T20:05:08Z2017-05-01T20:05:08ZA short history of anaesthesia: from unspeakable agony to unlocking consciousness<figure><img src="https://images.theconversation.com/files/166194/original/file-20170421-20054-iqgbuw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">General anaesthesia has come a long way since its first public demonstration in the 19th century, depicted here.</span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:History_of_surgical_anaesthesia,_Morton,_Diorama_Wellcome_L0003392.jpg">Wellcome Library, London/Wikimedia</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>We expect to feel no pain during surgery or at least to have no memory of the procedure. But it wasn’t always so.</p>
<p>Until the discovery of general anaesthesia in the <a href="https://www.woodlibrarymuseum.org/history-of-anesthesia/">middle of the 19th century</a>, surgery was performed only as a last and desperate resort. Conscious and without pain relief, it was beset with unimaginable terror, unspeakable agony and considerable risk. </p>
<p>Not surprisingly, few chose to write about their experience in case it reawakened suppressed memories of a necessary torture.</p>
<p>One of the most well-known and <a href="http://burneycentre.mcgill.ca/other_lettersjournalshemlow.html">vivid records</a> of this “terror that surpasses all description” was by <a href="http://burneycentre.mcgill.ca/bio_frances.html">Fanny Burney</a>, a popular English novelist, who on the morning of September 30, 1811 eventually submitted to having a mastectomy:</p>
<blockquote>
<p>When the dreadful steel was plunged into the breast … I needed no injunctions not to restrain my cries. I began a scream that lasted unintermittently during the whole time of the incision … so excruciating was the agony … I then felt the Knife [rack]ling against the breast bone – scraping it. </p>
</blockquote>
<p>But it wasn’t only the patient who suffered. Surgeons too had to endure considerable anxiety and distress.</p>
<p><a href="http://www.magonlinelibrary.com/doi/abs/10.12968/hmed.2014.75.3.174">John Abernethy</a>, a surgeon at London’s St Bartholomew’s Hospital at the turn of the 19th century, <a href="http://catalogue.nla.gov.au/Record/1046414">described</a> walking to the operating room as like “going to a hanging” and was sometimes known to shed tears and vomit after a particularly gruesome operation.</p>
<h2>Discovery of anaesthesia</h2>
<p>It was against this background that general anaesthesia was discovered.</p>
<p>A young US dentist named <a href="http://www.sciencemuseum.org.uk/broughttolife/people/williammorton">William Morton</a>, spurred on by the business opportunities afforded by technical advances in artificial teeth, doggedly searched for a surefire way to relieve pain and boost dental profits. </p>
<p>His efforts were soon rewarded. He discovered when he or small animals inhaled sulfuric ether (now known as <a href="https://pubchem.ncbi.nlm.nih.gov/compound/diethyl_ether">ethyl ether</a> or simply ether) they passed out and became unresponsive.</p>
<p>A few months after this discovery, on October 16, 1846 and with much showmanship, Morton anaesthetised a young male patient in a public demonstration at <a href="http://www.massgeneral.org/anesthesia/about/history.aspx">Massachusetts General Hospital</a>. </p>
<p>The hospital’s chief surgeon then removed a tumour on the left side of the jaw. This occurred without the patient apparently moving or complaining, much to the surgeon’s and audience’s great surprise.</p>
<p>So began the story of general anaesthesia, which for good reason is now widely regarded as one of the <a href="https://www.theatlantic.com/magazine/archive/2013/11/innovations-list/309536/">greatest discoveries</a> of all time.</p>
<h2>Anaesthesia used routinely</h2>
<p>News of ether’s remarkable properties spread rapidly across the Atlantic to Britain, ultimately stimulating the discovery of <a href="https://pubchem.ncbi.nlm.nih.gov/compound/chloroform">chloroform</a>, a volatile general anaesthetic. </p>
<p>According to its discoverer, <a href="https://www.britannica.com/biography/Sir-James-Young-Simpson-1st-Baronet">James Simpson</a>, it had none of ether’s “<a href="https://soap.org/chloroform.php">inconveniences and objections”</a> – a pungent odour, irritation of throat and nasal passages and a perplexing initial phase of physical agitation instead of the more desirable suppression of all behaviour.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/166196/original/file-20170421-20068-bb7yqi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/166196/original/file-20170421-20068-bb7yqi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/166196/original/file-20170421-20068-bb7yqi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=902&fit=crop&dpr=1 600w, https://images.theconversation.com/files/166196/original/file-20170421-20068-bb7yqi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=902&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/166196/original/file-20170421-20068-bb7yqi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=902&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/166196/original/file-20170421-20068-bb7yqi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1133&fit=crop&dpr=1 754w, https://images.theconversation.com/files/166196/original/file-20170421-20068-bb7yqi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1133&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/166196/original/file-20170421-20068-bb7yqi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1133&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This chloroform inhaler was the type John Snow used on Queen Victoria to ease the pain of childbirth. Chloroform vapours were delivered down a tube via the brass and velvet face mask.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Snow-type_chloroform_inhaler,_London,_England,_1848-1870_Wellcome_L0058154.jpg">Science Museum, London/Wellcome Images/Wikimedia</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Chloroform subsequently became the most commonly used general anaesthetic in British surgical and dental anaesthetic practice, mainly due to the founding father of scientific anaesthesia <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1325279/">John Snow</a>, but remained non-essential to the practice of most doctors.</p>
<p>This changed after Snow gave Queen Victoria chloroform during the birth of her eighth child, Prince Leopold. The publicity that followed made anaesthesia more acceptable and demand increased, whether during childbirth or for other reasons. </p>
<p>By the end of the 19th century, anaesthesia was commonplace, arguably becoming the first example in which medical practice was backed by emerging scientific developments.</p>
<h2>Anaesthesia is safe</h2>
<p>Today, sulfuric ether and chloroform have been replaced by much safer and more effective agents such as <a href="https://www.medicines.org.uk/emc/medicine/49">sevoflurane</a> and <a href="https://www.medicines.org.uk/emc/medicine/41">isoflurane</a>. </p>
<p>Ether was highly flammable so could not be used with <a href="http://emedicine.medscape.com/article/2111163-overview">electrocautery</a> (which involves an electrical current being passed through a probe to stem blood flow or cut tissue) or when monitoring patients electronically. And chloroform was associated with an unacceptably high rate of deaths, mainly due to cardiac arrest (when the heart stops beating).</p>
<p>The practice of general anaesthesia has now evolved to the point that it is among the safest of all major routine medical procedures. For around <a href="https://www.nap.edu/read/9728/chapter/1">300,000</a> fit and healthy people having elective medical procedures, one person dies due to anaesthesia.</p>
<p>Despite the increasing clinical effectiveness with which anaesthesia has been administered for over the past 170 years, and its scientific and technical foundations, we still have only the vaguest idea about how anaesthetics produce a state of <a href="https://theconversation.com/what-makes-us-conscious-50011">unconsciousness</a>.</p>
<h2>Anaesthesia remains a mystery</h2>
<p>General anaesthesia needs patients to be immobile, pain free and unconscious. Of these, <a href="https://theconversation.com/is-anyone-there-about-consciousness-and-its-disorders-54035">unconsciousness is the most difficult</a> to define and measure.</p>
<p>For example, not responding to, or then not remembering, some event (such as the voice of the anaesthetist or the moment of surgical incision), while clinically useful, is <a href="https://theconversation.com/scientists-find-way-to-predict-who-is-likely-to-wake-up-during-surgery-53217">not enough to decisively determine</a> whether someone is or was unconscious.</p>
<p>We need some other way to define consciousness and to understand its disruption by the biological actions of general anaesthetics. </p>
<p>Early in the 20th century, we thought anaesthetics worked by dissolving into the fatty parts of the outside of brain cells (the cell membrane) and interfering with the way they worked.</p>
<p>But <a href="http://www.nature.com/nrn/journal/v5/n9/full/nrn1496.html">we now know anaesthetics directly affect the behaviour of a wide variety of proteins</a> necessary to support the activity of neurones (nerve cells) and their coordinated behaviour.</p>
<p>For this reason the only way to develop an integrated understanding of the effects of these multiple, and individually insufficient, neuronal protein targets is by developing testable, <a href="http://www.nature.com/neuro/journal/v20/n3/full/nn.4497.html">mathematically formulated</a> theories.</p>
<p>These theories need to not only describe how consciousness emerges from brain activity but to also explain how this brain activity is affected by the multiple targets of anaesthetic action.</p>
<p>Despite the tremendous advances in the science of anaesthesia, after almost 200 years we are still waiting for such a theory.</p>
<p>Until then we are still looking for the missing link between the physical substance of our brain and the subjective content of our minds.</p><img src="https://counter.theconversation.com/content/74748/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Liley receives funding from the James S. McDonnell Foundation. He owns shares in Cortical Dynamics Ltd. </span></em></p>Terrifying accounts of surgery 200 years ago remind us how far general anaesthesia has come. Yet we still know little about how anaesthetics alter consciousness.David Liley, Professor, Centre for Human Psychopharmacology, Swinburne University of TechnologyLicensed as Creative Commons – attribution, no derivatives.