When Danny Fleet needed surgery for a dental abscess, he asked his colleague Chris Frerk to anaesthetise him…
“I think we could benefit from a few pictures on the ceiling before going off to sleep here.”
“Shall I put the paediatric mobile on for you?”
As a junior anaesthetics registrar, attending numerous lists and enduring countless examinations, I thought that when the time came for me to undergo my own first general anaesthetic I would be well prepared for what to expect. I discovered, however, that this is far from the truth. The age-old question of ‘Do we know too much?’ was very much applicable.
The first question for me was whether to have the procedure performed at the place I worked or transfer to a different hospital. For every disadvantage of staying at the hospital I worked at, I could think of many more advantages. Overall, the selling point to me was the ability to request who could give my anaesthetic and who could perform the surgery. This was very reassuring as I knew I would be in safe hands. In moving to a different hospital I would lose all control and for any anaesthetist that is a fear for us all.
We were doing a list together (a dental list), when Danny mentioned that he’d been trying to get an abscess on his tooth sorted for some time. He asked for suggestions from the surgeon about what was best for his tooth and got a formal referral to the max fac department. As he was new to the hospital I took him up to their outpatient department, did the introductions, then basically left him to it.
Next thing, Danny was asking if I’d give him an anaesthetic. My immediate response (in my head) was no as I thought he meant there and then, without going through POAC etc.; but when I realised this was for an official hospital visit I agreed.
Over the years I’ve come to recognise that there are all sorts of reasons why people choose particular anaesthetists to look after them (clinical skills, don’t leave theatre, don’t spend all their time on the phone or reading a book, don’t get flustered easily, same gender, don’t ever gossip about what they’ve seen or heard or they’ve looked after them well before). It’s always nice to be asked but equally I completely understand if a member of staff wants to choose someone other than me and I really don’t need to know why, and I don’t get offended.
How do I act as a patient? I had never been in this situation before and it was interesting discovering how to be a non-demanding patient, especially in the day case unit where I would regularly attend my lists. There may be few perks to working in the NHS at this point in time, but a definite highlight is being looked after very well by people you know.
Standing in my flattering patient gown feeling all the draughts, I was initially confronted by one of the novice trainees for pre-assessment. This is not what had been arranged but after a quick conversation they made their apologies and attended another list. Thankfully then in walked my consultant. A slightly daunting process I may add, as the main question running through my head was “what if he finds something out that I never knew?” Equally daunting was “what he is going to think of my lifestyle?” In actual fact this was not a problem, and I was very well relaxed by my consultation. I was then escorted to the anaesthetic room, only this time the doors to day case looked very unfamiliar and looming. The room itself felt alien to me as a patient. This was probably due to lying gazing up at the grey ceiling. At this point, I remember noting how bland and uninteresting the anaesthetic rooms were.
“I think we could benefit from a few picture on the ceiling before going off to sleep here.”
“Shall I put the paediatric mobile on for you?”
“Please,” I said. My response was met by the switching on of the paediatric mobile display. Bizarre as it sounds, this was actually soothing and a great distraction, even to an adult. It took my mind off being cannulated and being attached to the monitors. Even the constant beeping of the pulse oximeter and other alarms seemed a million miles away and trying to count my heart rate was expelled from my mind.
Then the oxygen mask came down. I have always been very wary of looming above someone at this time and holding the mask. I tend to ask if they want to hold it themselves, being aware of the claustrophobic environment it might produce. I expected that I would be peering up into the eyes of my consultant but I couldn’t see anything much. I have subsequently changed my idea of this practice. While I still let the patient hold the mask, I am now aware that this is not necessarily as daunting for them as I previously thought.
As bizarre as it sounds, the last thing I remember pondering was the effects of propofol. We are all taught that propofol stings on injection. To me I felt a tight feeling around my thumb as if the blood pressure cuff was going up. I felt a cold tingle travelling up my arm and I experienced a strange taste in my mouth. All these things are incorporated into our spiel and are surprisingly true. There was no sudden loss of consciousness and blackness, but a gradual surrender of will into undreaming sleep.
What technique to use? In general I’ve always thought it’s a sound policy to give the anaesthetic that you normally give (it’d be the one you’d be best at giving, and if it’s not good enough for a colleague then it’s not good enough for any other patient).
Danny and I had worked together with a novice trainee a couple of weeks previously and Danny had seen me giving them some experience at airway management. His request was simple: “Can you make sure for my anaesthetic you don’t let a novice anywhere near me?” This was easily done – the list was booked and I was solo anaesthetist, with noone to train.
On the day of Danny’s operation there was a minor glitch when a novice (seeing I had a solo list) decided to come and help by seeing some patients; he and Danny both got a surprise when he went into the room. Said novice quickly excused himself from the list.
From then on, from my point of view, it was absolutely routine; WHO checks done, cannula and chat. Danny commented that we could do with some pictures on the ceiling. We’ve heard that before and have a projector that displays fishes onto the wall – it keeps the children entertained – so I turned it on. After that it was preoxygenation, 75 of fentanyl followed by 180 of propofol; induction was smooth and the laryngeal mask slid in nicely (just like normal) and Danny was breathing nitrous oxide oxygen isoflurane with a steady heart rate and blood pressure within a couple of minutes. We transferred into theatre and hooked up to the breathing system in there. As the staff gathered for the ‘time out’ Danny surprised me by reaching quite precisely for his LMA! Not my proudest moment but some reassuring words, “all right Danny it’s all going fine,” another slug of propofol and all settled down again quite quickly. We did the time out and surgery was uneventful, and Danny was stable throughout, then it was 6.6. of dexamethasone and 1.25 of droperidol to minimise the chances of nausea and vomiting followed by routine handover to recovery staff then back to the anaesthetic room and on to the next case…
I thought I would dream and I convinced myself I did, for as I was waking in recovery I heard voices around me. In my head I can clearly remember walking down a corridor talking to my other half. In hindsight I realise that I was mumbling nonsense to the recovery nurses, but it was oh so real to me at the time.
If you ask a hundred people what they feel like after an anaesthetic, you will many different answers. For me there was a mixture of feelings. Initially I felt amazing, but as time went on, I gradually felt worse. It is difficult to put into words but I felt like that moment when you have had one too many drinks and the room is spinning. That helpless feeling that this was going to stay for a while and there was nothing I could do. The only way to explain it was that I just felt uncomfortable being in my own body. I wanted to sleep and be left alone but I couldn’t. I didn’t want to eat and I certainly didn’t want to get up, get dressed and sit and watch daytime television. I felt I just needed to get up, get out and get going. None of these things used to pass my mind when wheeling a patient into recovery, but they certainly do now.
Danny took a long time (20 minutes) to wake up and when I nipped in to see him in recovery he was pretty spaced out. I didn’t know at that time how he was feeling and as far as I was concerned he just seemed a bit more sleepy than I would have expected. I planned to see him later in the second stage recovery area but he’d gone home by the time the list was finished.
I could still taste the volatile for the next 8 hours and I wasn’t allowed to brush my teeth or rinse my mouth (although even if I had it probably wouldn’t have made much of a difference). I also felt uncomfortable in my own body. I wanted to lie down but this made me feel jittery and like I wanted to move position. This bizarre feeling lasted for 24 hours after my operation.
When I was feeling a bit more human I decided to send Chris a message of thanks. I had asked him to be my anaesthetist for a multitude of reasons (friendship, knowledge, experience, etc.) but mostly because I trusted him. I knew I was in safe hands with him and he delivered. Plus I had no pain and no nausea. It was only later that I appreciated that I had been a lot more nervous than I had let on.
It’s rare to get the opportunity for informed feedback and it started that evening. For the first time in my career I got early feedback via social media. It read:
Thank you dr Frerk for today. You were a true legend and felt so safe. Now if I could get the taste of sevo out my mouth and have feeling return to my lips then ill be even better. You are a legend. Thank you again Danny
I was well pleased by this as I hadn’t managed to see Danny before discharge. Aware that focusing on small screens can make you feel queasy but not wanting to appear churlish I sent a reply:
No worries, my pleasure (PS that’s the taste of Iso – I use the cheap stuff cos it’s supposed to have less N&V – hope that’s true). Came to see you at end of day (after you’d gone) rest well, see u when u get back
A message pinged back:
No nausea and vomiting just pretty washed out. think I was a tad away with the fairies in recovery for a while before I left but kinda needed to get up and get going else I would have slept the rest of the day away. once again though thank you so much for everything.
Feeling suitably chuffed I left it at that.
If there’s one thing I’ve come to understand about debriefs in the NHS it’s that we never have enough time to do them properly. Danny and I extended our debrief over several occasions after “the anaesthetic”. For the sake of simplicity we’ve rolled them into one.
I was really surprised that Danny could still taste the volatile for the 8 hours after the operation. A couple of hours OK, but 8 hours? I had no reason to disbelieve him and it made me wonder should I be using TCI Propofol more often? I’m quite comfortable with the technique but probably only use it for one in 10 anaesthetics I give even though I’m aware that patients report a better feeling of wellbeing after TCI than volatile anaesthetics.
The thing that resonated with me most however was a phrase he used during our first post-op conversation: “It was quite unpleasant, I just felt uncomfortable in my own body.” I immediately thought of droperidol and discussed this with Danny. It sounded exactly like a description of a side-effect of droperidol that I remembered learning about during my trainee days. On preop visits patients occasionally tell me they felt rough for days after previous anaesthetics and I’ve usually explained it away as being due to the surgery but on this occasion I was sure that the straightforward extraction of a tooth was extremely unlikely to be responsible so the only logical explanation was “it was me”. Droperidol seemed the most likely culprit giving a ‘locked in’ feeling that Danny’s description seemed to capture so well (although we also discussed the possible effects of dexamethasone having a temporary psychotic effect, as described in a recent pro–con editorial in Anaesthesia). As a trainee, I had decreased my dose of droperidol down to 125mcg but I have subsequently been seduced by our hospital guidelines (and talks at national meetings) which recommend 1.25mg.
As trainees, we learn a whole encyclopaedia of drugs and their effects. Added to this we have our own and our consultant’s anecdotal tales of ‘this drug doing this’ and ‘that drug doing that’ which makes it difficult to find and understand what really works. We have all been on the side of a consultant teaching you his/her anaesthetic recipe and then, when left to do it by ourselves, it never ends the same way. In my case did I feel uncomfortable because that’s just what anaesthetics do, or because the droperidol is prescribed as too high a dose? Perhaps at lower doses, the antiemetic properties would supervene the locked-in effects. In addition, dexamethasone is a good antiemetic but the psychosis (if that is what it induced in me) from sudden increases in plasma levels is not justified.
So what have I learned from my first anaesthetic? First, never underestimate the patient – their cool calm exterior is most likely a façade. Secondly, don’t fear having procedures at places where you work. If anything, the level of trust is higher and this greatly reduces stress.
Next, anaesthetic rooms should be decorated. It’s not just kids that need distraction. A nice calming scene to look at as we drift off under our white-emulsion-fuelled dreams is just a small touch that can set you up for a good experience.
And finally, no matter what, ‘the best laid plans of mice and men gang aft agley’. Despite our continued ongoing learning, our human nature and learned behaviour from experience sometimes takes over. I will never know what it was that caused me to feel so uncomfortable, but, through a process of elimination, I will not be giving my patients droperidol in large doses. Like many of my colleagues believe, it truly is a devil of a drug.
My first thought was quite selfish. I really wanted to give Danny another anaesthetic (avoiding droperidol) to reassure him (in truth probably to reassure myself) that I could give a general anaesthetic without making the patient feel dreadful. However, I hope he doesn’t need another one and who knows whether he’d choose me again if he did!
My main reflection though is that if you have the privilege of anaesthetising a colleague, obviously look after them as well as you can but also be sure to take the opportunity to get the most informed feedback you will ever receive. If there’s one thing I’m sure of, the experience has helped me be a better anaesthetist than I was before, and that can only be a good thing.
Chris Frerk is a consultant anaesthetist.
Danny Fleet is an ST3 anaesthetist.
Both work at Northampton General Hospital.