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Three Letters Re: Anesthesia for Traumatic Times, by Scott N., EMT

Dear JWR:
As a practicing anesthesiologist, I felt it necessary to respond to Scott N.’s article about TEOTWAWKI [1] anesthesia. First, let me complement Scott N. for the well written article as well as bringing up the issue in the first place. Although it may be interpreted as self serving, I also have to strongly agree with JWR’s admonishment that this is not something to “try at home”.

In a sense, we in the anesthesia field have somewhat become victims of our own success. It wasn’t that long ago that the risk of anesthesia (not the risk of the surgery) was the main consideration in whether a surgical procedure was even attempted. Today, you are probably more likely to die in a car accident driving in to the hospital for your electively scheduled surgical procedure, than from anesthesia. Anesthesia practitioners used to have one of the highest rates for medical malpractice insurance, now it is one of the lowest. These advances in patient safety are multi factorial. Anesthesia providers are some of the most highly trained individuals in the medical field, advances in monitoring (both invasive and non-invasive) has completely eclipsed what was available even 20 years ago and medications, while becoming much more potent, have also become much more precise in their effect. These three factors have led to the risk of anesthesia becoming almost an afterthought.

In a TEOTWAWKI situation, all three of these factors would likely be unavailable. One should be reminded that “lethal injection” is in effect an induction of general anesthesia (the initial medications are the same), and the only difference is the absence of an anesthesia provider at the patients head. It has been stated (although a significant exaggeration), that sodium thiopental (Pentothal) killed more Americans at Pearl Harbor than did the Japanese.

There are three main types of anesthesia. The first being General Anesthesia (GA), which is a state of unconsciousness and is the normal public perception of what anesthesia is. General anesthesia is described as a triad of states: Analgesia (lack of response to painful stimuli), Amnesia (lack of memory of the event) and Muscle Relaxation (a reduction or obliteration of muscle tone). General anesthesia is accomplished by a combination of medications administered by intravenous and/or inhalational routes. General anesthesia requires that the anesthesia provider take responsibility for the patient’s ABC [2]‘s (Airway, Breathing and Circulation). The second is Regional Anesthesia, which is accomplished by injecting local anesthetics (numbing medicine) around a central or major peripheral nerve, thus effecting anesthesia in a “region” of the body, such as an arm or leg or “below the waist”. Spinal, epidural and brachial plexus blocks are routine examples. The third is local anesthesia, which is accomplished by injecting local anesthetics into the soft tissues around the area where a procedure is performed. Typical examples are dental procedures and wound closure (stitches). Even though the latter two do not necessarily include a state of unconsciousness, supplemental sedation, which frequently causes amnesia, leads many people to believe that they “went to sleep” (i.e. were under general anesthesia) when in fact they were not.

In a survival situation, infiltration or local anesthesia would be the preferred technique. An experienced surgeon can even perform an appendectomy under infiltration anesthesia. While local anesthetic drugs (lidocaine, bupivicaine etc.) do have toxic side effects, these can be mostly prevented by avoiding injecting directly into an artery or vein (aspirating the syringe before injecting) and avoiding a “toxic dose” by using no more than one bottle for an adult (this is an oversimplification but is correct more times than not). Having an inexperienced individual stick needles into major nerves or take responsibility for a patient’s ABC’s raises the risk profile to astronomical proportions. – NC Bluedog


I feel compelled to say that as a subject matter expert–an MD [3] Anesthesiologist, in fact–on administering anesthesia, the publication of the article, ” Anesthesia for Traumatic Times, by Scott N., EMT” is fraught with peril. I wouldn’t have published it.Your web site lends an aura of credibility to whatever people read there, at least it does to me. It can however encourage people to try things that they ought to think twice about. More to the point, it can make people believe they are more medically trained than they actually are. As such, the article on anesthesia shares in that aura which it simply does not merit!

Although the author begins to describe the classic “Stages” of General Anesthesia, he should point out that while we in the business still do refer to “Stage 2” under certain circumstances; proper use of these stages is described only for ether anesthesia. Even though the author then goes on in fact to describe the use of ether; I will describe why no one should.

The author then confuses these stages with the goals of an anesthetic: Asleep (unconsciousness), Analgesia, Amnesia, Akinesia, and Autonomic Stability- colloquially known as the Five “A’s” of Anesthesia. I guess that I am a purist, but if the author is going to describe such a “make do with what you have” in a SHTF [4] scenario on such a serious and potentially deadly topic, then the terms should be used as they are professionally understood.

As a matter of background and to make a point, the most standard sedation scale we use is the Ramsay Scale, which describes everything in six stages from mild sedation (peaceful, tranquil, awake and aware) to deep anesthesia (stone-cold out; complete with loss of airway, respiratory arrest, and vital sign changes). The point is: As a rule, a practitioner must be trained to manage an airway of a patient one level deeper than the anesthesia you plan to administer. In other words, at Ramsay score of 3 (what is commonly referred to as “moderate sedation”, “conscious sedation” or “twilight anesthesia”); the patient still maintains their own airway; but at stage 4 can begin to lose airway reflexes; even the practitioner of moderate sedation needs to be able to manage a [compromised] airway. You are not only substandard; you are dangerous if you can’t!

How does this relate to the original article: vinyl ether was never popular since it induced deep anesthesia too quickly. Oops, that was fast- hope for your patient’s sake that you know how to manage the airway! The author, an EMT [5], certainly can- what about your readership at large?

Also, ether doesn’t just make you a little sick; it is (or was) notorious for causing post-op nausea and vomiting. It caused intra-op nausea and vomiting! Vomiting is one thing, but sucking the vomitus back into your lungs, called aspiration, is a catastrophe. The mortality approaches 30% in young, healthy patients, and leaves them with the lungs of a 70-year smoker if they survive. Aspiration gets worse from there. Prevention of aspiration, for those who don’t know, is the main reason we ask people to fast before surgery- so their stomachs are as empty as possible.

In addition, giving herbal extracts and whatnot by mouth increase the amount of stuff in your stomach. Since adding ether to a stomach full of anything is a recipe for aspiration. Do not be fooled by saying that its barely a mouthful of total volume. The standard for having higher risk for aspiration is a paltry 25cc’s in your stomach. The average adult single “mouthful” ranges from 80-150cc’s.

Indeed, ether was almost abandoned in its infancy because of an aspiration death. A historical anecdote for another time.

There are some other bad effects, both pharmaceutical and physical, of the agents that need to be discussed. Ethers are associated with both acute and delayed hepatic necrosis, and even hepatic failure; they are flammable as both liquid and gas. The liquid is lighter than water and the gas heavier than air, so they can flow and migrate long distances to pick up a spark. And where diethyl ether is flammable (and explosive in enclosed spaces/high concentrations), vinyl ether is explosive! In fact, old operating rooms had extensive protections against heat, flame, sparks, even static electricity (rubber mats and rubber soled shoes in place, after a few demolished hospitals and personnel deaths! The fire potential of these agents is no joke.

More, is the “survival source’ of ether going to be pure? Common contaminants include peroxides, formed spontaneously by exposure to air(oxygen) which are explosive. Inhale that? not me.

Ultram, Toradol, etc- good drugs for their intended purposes- again if you know how to use them. I haven’t got too much to say on them at this time.

The herb that Mr. N spends a bit of time describing, Salvia divinorum, has of course not yet made it into the mainstream medical practice. I remain open to the idea, especially since I know Gamma-Hydroxybutyrate (GHB) would potentially be a boon to anesthetic practice; but because of bad press [about its nefarious and now notorious use as a “date rape” drug] will not be anytime soon. The “establishment” in medicine is well-known for badmouthing things that they don’t like (GHB, anabolic steroids, etc) even when faced with much evidence that the drug has useful medical purposes. So while I can’t say how effective the salvia is, I also can’t say its safe. Also, while inhalation anesthesia is well established in anesthetic practice, smoking is not. Especially smoking near [explosive] ether!

I have long thought of how I can potentially contribute to your work. Even though anesthesia is the skill I can most confidently share; I have resisted writing on the subject for the reasons expressed and implied in this letter. Sincerely, – Dr. Gaston Passer

I pray all is well with you and your family.
Scott N.’s article on Anesthesia is a fine piece to which I would add but little:
Creative use of local anesthetics can preclude the need for a general anesthetic.

1.) Hematoma Blocks: This involves injecting the local anesthetic (no epinephrine) directly into the blood collection at the site of the fracture, etc. This method provides excellent relief for setting bones or otherwise dealing with the appropriate trauma.

2.) Regional Blocks: This method combines a knowledge of anatomy with local anesthetics to block sensation in a nerve bundle supplying a specific region. Although easy in practice, it is best to use a textbook to guide you.

Look around for texts like Regional Anesthesia: An Illustrated Procedural Guide, by Mulroy. There are many fine ones out there. {Remember latest edition is not always greatest edition. Many times medical book edition changes are there to just add the newer drugs and many times they drop “older”, but more practical information.}
Hypnosis is a relatively easy to learn and very effective technique for pain control and anesthesia. Most people are susceptible. I’ve seen it used in major knee replacement surgery with success. I have personally used self-hypnosis it for pain control at times.

One other note: Tramadol is an excellent painkiller. It has a fairly rapid onset, relieves a high degree of pain effectively and is a non-schedule (not subject to DEA [6] scrutiny) drug. On the down-side, it is addictive (although the PDR [7] denies this). Having worked with numerous patients who began taking it according to recommendations, I have seen that even those who never exceeded the proper dosage have a difficult time withdrawing off of it. It appears to affect the serotonin system (same system affected by newer antidepressants and ecstasy) in the brain to a degree beyond the measurable blood levels after taking it for even a short time. I have not precluded use of it in my kit, however. Forewarned is forearmed. My recommendations are to use it sparingly and infrequently. In those instances where a continuous high degree of pain relief is necessary, expect the withdrawal to occur. It can last up to two to four weeks. Thanks to Scott N. for his excellent article and to you, James, for your efforts to assist all of us. – Doc Gary

JWR Replies: I must repeat the proviso to SurvivalBlog readers that anesthesia is an art and science that should be left to professionals. Don’t kid yourself into thinking that reading a few textbooks somehow qualifies you for anything beyond administering a light local anesthetic, if and when times get Schumeresque [8]. A little knowledge is a dangerous thing!