Ask me anything with anaesthetist Dr John Currie
Tuesday 25 September 2018
For most of us, what happens in an operating theatre is a mystery. For Dr John Currie, surgery is an everyday occurrence.
Dr Currie has been practising as an anaesthetist for 40 years this September. He initially trained as a paediatrician in Scotland, but after witnessing and being amazed by the work of the anaesthetist who treated his cardiac patients, he moved into paediatric anaesthetics.
Jump forward a few decades and Dr Currie found himself taking a post as Director of Anaesthetics at Mount Isa Hospital. After finishing up his work at Glasgow Children’s Hospital, he and his wife packed their bags and moved down under.
“We went to Noosa for a week,” Dr Currie recalls, “and really we thought we'd died and gone to heaven. I think Castaways Beach is one of the most beautiful places I've seen in the world. It takes your breath away. It's beautiful.
“Then we got in a plane and we crossed the desert for hour after hour, and we came to Mount Isa. We looked to see where the mountain was! We walked around in the heat at the end of October, and we thought, how do people live here? We're going to die.”
But Dr Currie and his wife have adjusted to both the climate and the unique challenges of work in a remote hospital.
“There's a great team here and we've made ourselves at home,” he says. “Coming here was a completely different thing. I had to go back to my old skills in anaesthesia. Having specialised paediatrics was great, it's good to have someone who can do that here.”
Dr Currie made time in his busy schedule to talk to us about the weird and wonderful world of anaesthetics, answering the most common, and some uncommon, questions about his job.
What’s it like the first time you put someone under?
It's amazing. It really is like taking a person away. You've got a person you're talking to and then you have somebody who's going to have an operation, and you're looking after their body functions and wellbeing. But actually, the consciousness has gone.
One story that's really stuck in my mind was one little girl that I anaesthetised. When I was talking to her afterwards she said, "This is the man who gave me an injection and I disappeared." And that's kind of right! The patient, as a person, is going to disappear for a time.
What does an anaesthetist do during surgery?
People think you just put the patient off to sleep and then walk away - we don't, it's quite an intense thing and you'd be glad that we're there!
Administering the anaesthetic itself during the operation is a continuous process. We usually use inhalation agents, so we're constantly adjusting that. We're making sure that the patient parameters – blood pressure, pulse and so on – are right. Basically, we are there on a second-by-second basis, making sure that the patient's physiology is optimum.
We also have a lot of different roles in the hospital: we run pain clinics, we run ICUs, we do epidurals. A big part of the job is resuscitation; we're good at airway skills and resuscitating people.
Is there an average day for an anaesthetist?
Every day is kind of different and that's the exciting part.
We turn up first thing in the morning, we have a huddle with the surgeons, and then we plan the day depending on the emergency surgeries we know about. There'll be the list of patients for that day. And then you work through that list, including the emergency additions. Each week we have a meeting to make sure that suitable patients are booked for each list.
But during that time there might be calls to come and look at patients in the ICU, there might be an emergency caesarean section where we have to stop everything and get that done. There might be an epidural to do down in maternity.
It's planned and unplanned, and mostly just making sure that you try to get everything done that you need to in the day.
Is it true that we don’t completely know how anaesthetics actually work?
That’s a very good question. There are several theories, but there's no one theory that fits all the facts.
Basically, anaesthetics disrupt the transmission of information between nerve cells. And there are all sorts of tiny molecules like little gases that do it, and big molecules like induction agents that do it. The more connections there are between nerve cells, the more the anaesthetic tends to work.
Imagine passing a communication along a chain of 100 nerve cells. That message is going to be blocked by an anaesthetic easier than passing information from one cell to another cell. Consciousness is at the highest level of brain activity with many interconnections between brain cells.
What’s the difference between a general anaesthetic and a local anaesthetic?
A general anaesthetic is where the patient is unconscious. You anaesthetise the whole person. A local anaesthetic is to numb up a particular area.
Local anaesthesia is what you have at the dentist. You have an injection so the tooth and gum goes numb and you can have the tooth filled. It's just numbing up the part. And I think that's much less of a trauma for the patient. Having a general anaesthetic, the whole patient is unconscious.
How do you choose what type of general anaesthetic to give each patient?
There are two basic general anaesthetics. Think of it like there are different recipes, but two basic dishes.
There’s one where the patient is unconscious and paralysed, so that their muscles are relaxed, and that means the surgeon can use a much smaller incision, so there's less trauma.
And the other type of anaesthetic is where the patient is breathing spontaneously and not paralysed. This is used for lesser things, where the surgery isn’t entering body cavities.
Is it possible that I will wake up during surgery?
People worry a lot about that! No, I think that would be extremely unusual nowadays.
It certainly has happened in the past, when patients had paralysing anaesthetics, and if people weren't taking care, they could wake up. Because they were paralysed they couldn’t tell you. That's dreadful.
We used to have to rely on patient factors, whether they got tachycardia (a fast heartbeat) or sweating and so on, to tell someone’s consciousness. We now have machines that will measure the activity in the brain. We can look very carefully at how deeply unconscious a patient is. And because the monitoring is so much better, we have a second-by-second knowledge of what's happening to our patients.
A lot of research has been done about it. It would be very, very unusual now. So, don't worry about that!
Why can’t I eat or drink before my surgery
This is important. The main thing is to avoid vomiting on induction or on emergence from anaesthesia. If you vomit when you're half asleep or half awake and you haven't got a good cough reflex, then the fluid can go down into your lungs. So, we really don't want a full stomach for anaesthesia.
The other thing is that if you're having an abdominal operation, obviously a stomach that's full is going to take up a lot more space. We do a lot of keyhole surgery now, so you really want the stomach to be empty and tucked up out of the way.
Why shouldn’t I wear nail polish to surgery?
We have an instrument called a pulse oximeter which shines light through the fingers or the toes. It's a magical machine, it tells you how much oxygen is in the blood. When these machines were first introduced the worry was that if you're shining light through the finger and you have nail polish, the polish would affect the way the light was shining through.
With the new pulse oximeters, it really doesn't matter as much, but it’s important for patients to stick to the surgery guidelines they’re given. There's been lots of research done on different colours of nail varnish – dark brown and black might affect it a little bit. Interestingly, the way nail varnish is made in the UK, Europe and Australia is different to America. So, it's more of a problem in America.
Some units will insist on it because they like to see the nail bed. It's one of the places on the body including the eyes and the mouth where you can actually see the blood colour. So, we can can see if you've got nice pink nail beds, as part of monitoring oxygenation.
Why can’t I wear deodorant to surgery?
Deodorants can have alcohol in them. We use a diathermy machine which can make a little spark, and we really don't want to have an explosion because there's alcohol in your armpit.
Why do you ask people to ‘count back’ when you’re putting them under?
That's just a way of getting a patient to take their mind off going to sleep. The kids we ask to blow up balloons. Sometimes we say just try to keep your eyes open.
It just gives an indication of how much of the anaesthetic that patient is going to need to go off to sleep. We adjust the drug until they're unconscious.
How long do people usually ‘count back’ for?
Most people counting back from 10 wouldn't make it past 5. It's amazing. And then they wake up afterwards and ask, “When are you going to start?”.
How do you reverse the anaesthetic after an operation?
Mostly, it's just a process of the anaesthetic wearing off. If we use paralysing drugs, then we do reverse those with reversal agents. And sometimes if we want to reverse the effect of narcotics or sedatives, then we can use drugs to do that.
Generally, we adjust the dose so that it wears off nicely and the patient is still pain free and anxiety free, and not sick at the end.
Why do some people react badly to anaesthetics?
We usually know why. People are allergic to different drugs and they'll usually tell us that beforehand. Some people can have a major allergic response, which is anaphylaxis – you can have the same thing to bee stings. There are types of syndromes – people with different enzymes or lacking enzymes – that can react very badly to anaesthetics. But they're rare and well documented now.
Of course, everyone's different. When I'm teaching, students will say, “What's the dose of this?” and “What's the dose of that?” I'll say, “Well, how many pints of beer does it take to make a medical student drunk?” There's a range of doses; we get to know from our skill and experience exactly what to give. We very rarely have a bad reaction to anaesthesia.
There are certain groups of patients – women particularly having gynae operations – who tend to have nausea afterwards. We've got a lot of good drugs for that. Speaking as a pathetic man I'd rather have pain than feel sick, so I really do my best to make sure no one gets nausea after anaesthesia!
Do people with red hair really react badly to anaesthetics?
That's been a myth that's been going on for ages. The main thing was that red heads tend to bleed more. There was a paper about six years ago which investigated this scientifically. It was a bit of a tongue-in-cheek thing, but they did it with the proper procedure. And there was an increase in blood loss in redheaded patients, but it didn't reach statistical significance.
So, if you're red headed you're okay: it's more of a myth.
Do anaesthetics really stop you from feeling pain, or just from being aware of it?
With anaesthesia you're really taking away quite a lot of the brain function; your consciousness particularly. However, the input to the brain continues.
For example, if you whisper in somebody's ear, the hearing mechanism is going to happen. The little bones in the ear will move and a message will be sent to the brain, but it's not going to get into the consciousness.
People have looked into whether you can actually make memories when you're under anaesthesia. This is a bit like the work on sleep-learning. There is still quite a bit of brain activity going on – and that's a good thing, you don't want to depress brain activity too much– but it's not going into the consciousness.
So, no you don't feel it. These messages are coming into the brain and it’s processing those signals, but it's not coming into consciousness.
What can I do to make my surgery go better?
Follow the fasting rules; this is very, very important. Don't smoke on the day of the operation. That can make you cough when you're waking up. It makes the airway a little bit raw.
Be honest with us. When we're asking question as to what drugs and alcohol you have taken, it actually affects what we're going to do. If people are on opiates, for instance, we need to know that. We need to give a different dose to make sure that they're pain free. If they're drinking two litres of rum a day then that affects their livers, for instance, and we need to know that. So be honest with the answers you give us.
What is the best part of your job?
To me, to see a patient pain free and comfortable in recovery after the operation is everything; I still get a kick out of that. The thing I really like is when they say, "When's the operation going to start?" And it’s all over. That's kind of cool. I think I've done a good job when they say that.
What would you tell someone who is interested in becoming an anaesthetist?
I tell people I've had the best job in the world. Anaesthetics is a very rewarding specialty and if you are interested, then go for it. I love teaching and seeing trainees develop their skills and knowledge.
I love the job. Particularly paediatric anaesthesia; kids are amazing. I love to see a little child turn over – they usually turn over to the side they like to sleep on – and cuddle up and go to sleep in recovery after an operation. You really can’t beat that for job satisfaction.
Many thanks to Dr John Currie for sharing your time and expertise, and to North West HHS for giving us access to your inspiring staff.