About anaesthetists General Anaesthetic Sedation Local Anaesthetic Epidural/Spinal

About anaesthetists

What is an anaesthetist?

In metropolitan Australian cities, the anaesthetist is a specialist medical doctor, who is tasked with ensuring the comfort and safety of patients undergoing surgical procedures.

Far more than just "putting you to sleep", having full general anaesthesia is akin to being put on "life support" - the anaesthetist takes over your airway and breathing; your blood pressure and heart rate; and ensure other body functions like kidney functions and brain functions are the best that can be achieved during surgery. This ensures that every surgery is performed in the safest physiologically possible way. The anaesthetist stays for the duration of your operation, keeping a watch on all your vital parameters, and adjusts them to suit your particular set of physiological conditions and surgical variables.

 

How does one become an anaesthetist?

One needs to be a doctor first and then specialise in anaesthesia. So a typical path, after graduation from high school, is: 6 years of medical school at a university, 1 year internship, 3 years as a junior resident doctor working in various specialties related to critical care and 5 years of formal specialty training in anaesthesia through the Australian and New Zealand College of Anaesthetists, while rotating through major hospitals as a registrar (= a doctor in specialty training). This assumes one is successful at passing all the hurdles and exams along the way on first attempt, and is able to secure a highly competitive training spot without any setbacks - only 1 in 10 doctors who apply for this training is accepted into the program, most by demonstrating ability and interest by undertaking anaesthesia related research and/or completing a masters degree first, which takes additional time commitment and dedication. Dr Jin Li has undertaken formal training in surgery and worked extensively in emergency departments as a senior-in-charge before embarking on training in anaesthesia.

 

Does the anaesthetist work for the hospital or the surgeon?

In public hospitals, the anaesthetist works for the hospital as a government employee.

In private hospitals, anaesthetists, like surgeons, are considered service providers independent of the hospital itself. Think of it as three separate members of a team - the hospital with nurses, the surgeon and the anaesthetist - all coming together under the one roof to help care for the patient, but are fundamentally financially separate to each other. This means you will receive separate bills from each provider.

 

What about Private Health Insurance and out-of-pocket expenses (gap)?

Private Health Insurance pays different amounts to the hospital, the surgeon and the anaesthetist for the one operation you are having. As a result, you will get charged different out-of-pocket expenses by each party.

In addition, the amount paid also varies by the insurance fund you are with. A cheaper insurance provider might charge you less premium, but it might pay less to the providers, resulting in a higher out-of-pocket burden to you.

Some insurance providers have different tiers of cover for you to choose. In general, a top level cover will often give you extras like physiotherapy or optometry services, but in fact doesn't provide any additional cover for the doctors' fees compared to a lower level cover. Therefore the out-of-pocket expenses payable to a doctor will likely to be the same regardless of your level of cover. Further details on this can be obtained from your provider.

In general, your out-of-pocket expenses for an anaesthetist varies between $0 to $500 for each operation. This can depend on many different factors. Difficult anaesthesia might attract higher gap charges. Long operations might attract higher gap charges. Each anaesthetist determines his/her own fees, much like your accountant, lawyer or mechanic. At the end of the day, most anaesthetists charge very  similar amounts in line with market forces.

Uninsured patients will incur much higher costs and will be quoted individually depending on the estimated difficulty and duration of the anaesthesia.

Occasionally, the fee estimate from the anaesthetist may exceed that from the surgeon. This is usually because you are having a relatively minor operation, but nonetheless require a full general anaesthetic in order to facilitate it. This is especially so if you have many pre-existing conditions that make anaesthesia difficult.

Very occasionally, the actual fee paid may vary from the estimate if the duration of the procedure is unexpectedly long or short. You will be advised of such dramatic variations and charged/refunded accordingly.

General Anaesthetic

What is a general anaesthetic?

General anaesthesia involves giving you medication, by injecting it first and then by breathing it in, in order to induce your brain into a state of unawareness. Often, a muscle relaxant is given in order for the anaesthetist to be able to insert a breathing device to help you breathe, and the for surgeon to be able to pull aside muscles that get in the way of surgery. Pain killers are given during surgery even though you are unaware, because your body still responds to pain in the usual way despite your not being aware of it - heart rate will dramatically increase, blood pressure will shoot up, and pressures inside the brain and other body compartments will increase also. All these can be detrimental to the body, especially if there is pre-existing problems with the heart, the brain, etc.

The unawareness induced by general anaesthetic drugs is most certainly NOT the same as the sleep you have every night, despite the anaesthetist telling you: "I am going to put you to sleep now." when inducing you. Think of it like this: if a surgeon was to try to cut you open with a knife while you are sleeping in the middle of the night, you will most certainly wake up and put up a fight. To ensure that you are not woken up by the painful stimulus of surgery, the brain and nerve functions will need to be depressed to a level much beyond what happens naturally each night in sleep. Unfortunately, at this sort of level of depression of brain function, your throat closes up; you stop breathing; your heart and blood vessels don't function well; you stop regulating body temperature; etc, etc. This is why you need a well trained anaesthetist to look after you during surgery.

 

Is general anaesthesia safe?

There has been significant advances in the medications, the breathing machines and anaesthetist training in the last few decades to make general anaesthesia extremely safe for otherwise healthy patients undergoing most surgical procedures. Risks naturally increase if you have pre-existing medical conditions, such as severe heart or lung diseases. Risks also increase if the surgery itself is high risk - such as heart or lung related procedures, or very long operations. Your anaesthetist is trained to anticipate the likely issues your particular body might encounter during a particular type of surgery and have customised plans (usually with 2 contingency plans) ready in advance, so that things go smoothly. This also means that even if things do go awry, they are often fixed seamlessly before any further deterioration occurs (plan B and C automatically kicks in). This means anticipating potential issues well in advance; having a full bank of emergency medications on hand and ready to deliver; as well as having a range of techniques and settings available to secure your airway and adjust breathing patterns on the machine. Sometimes, in order to ensure additional safety, your anaesthetist may choose to insert additional monitoring lines into your body in order to monitor your blood pressure/s more closely. This is often necessary for long surgeries in elderly patients, with heart conditions. Patient safety is a paramount concern to all service providers in surgery.

Sedation

What is sedation?

Sedation is a state somewhere between fully awake and fully anaesthetised – whether a patient is more on the awake side or the anaesthetised side depends on the requirement of the surgery and the patient, and can be tailored to suit by your anaesthetist.

Good sedation provides excellent anxiety relief and adequate conditions for minor procedures like gastroscopies, colonoscopies, superficial skin lesions and the like. Local anaesthetic injections can also be added on top of sedation to provide additional pain relief, if needed.

It is often the technique of choice for suitable patients because it avoids the burden of a full anaesthetic on the body. It causes less drop in blood pressure, which means less effect on the heart, the brain and other highly blood supply dependent organs. In addition, the patient would usually breathe for him or herself under sedation, without the need to be put onto a breathing machine. This avoids many hazards and complications associated with inserting airway devices to help patients breathe, which would normally be required if fully anaesthetised. It also means the patient becomes wakeful much faster, and allows for earlier discharge home.

Local Anaesthetic

What is a local anaesthetic infiltration?

Instead of depressing the functioning of the brain with a general anaesthetic, a local anaesthetic can be injected to temporarily depresses the functioning of the smaller nerves near the operative site. Due to the chemical composition, the injection often hurts at the beginning. But once done, it is able to provide many hours of complete painlessness to the area. Only certain types of operations can be done this way, typically small operations like superficial skin lesions.

What is a local anaesthetic block (also known as a regional anaesthetic or nerve block)?

Similar to a local anaesthetic infiltration, but instead of injecting around the operative site, the injection occurs next to a nerve that eventually runs towards the operative site. By "blocking" this nerve before it reaches the operative site, this technique knocks out your body's ability to relay pain signals from the area supplied by this nerve back to your brain. An example is when the injection occurs around the base of your fingers (near the palm) and yet operating on your finger tip produces no pain - the pain signal sent back by your finger tip is "blocked" once it reaches the palm and cannot go on towards the brain.

Some operations can be done with a local anaesthetic block alone, because it can reliably produce complete pain relief.

For other operations, a local nerve block is used only as a supplement to a general anaesthetic, because the block is insufficient by itself to provide complete pain relief. This is because there are often multiple nerves that supply the same operative area and not all of them can be reliably blocked out in entirety or for long enough to outlast the operation.

What about spinals or epidurals?

The principles behind a spinal block or an epidural block are the same as a local anaesthetic block - the difference being that instead of blocking a small nerve in a limb, a spinal/epidural (temporarily) blocks the entire spine below the level where it is injected. In high enough doses, this is able to provide complete pain relief adequate for any surgery below the chest.

Please click the Epidurals/Spinal tab for further detail.

Epidural/Spinal

What is an epidural?

An epidural is an injection that aims to numb down the lower half of your body to provide pain relief and adequate conditions for surgery.

It is named after the space where the local anaesthetic drugs are injected to achieve this effect – the epidural space, which is a tiny, almost non-existent space that sits just outside of your spine. An epidural is therefore done by “feel”, that is: advancing a needle attached to a pressurised syringe – when pressure is lost, it indicates that the needle has found this tiny space. Expert technique and patient cooperation is therefore very important at a successful epidural insertion.

What is a spinal?

A spinal block is similar to an epidural, with some crucial differences. The needle used is much much smaller, but it goes slightly closer to the spine than an epidural. Like an epidural, this is also done by feel, but it pierces the tiny epidural space, and instead ends up 2 layers further in. The correct positioning is signaled when a small amount of the "suspension fluid" around your spine leaks back out the needle.

Given the similarities, how does the anaesthetist choose which of these two techniques is used?

More to come.