Health: It only hurts when I look

More and more Americans are staying awake during operations. Would you go under the knife with just a local anaesthetic? By Roger Dobson

The patient lying on the operating theatre table is chatting about her holiday in the wilderness of Montana to just about anyone who will listen.As she tells how she and the kids went horse riding, sang around campfires and ate barbecued ribs, she seems unaware that her left leg is lying at an alarmingly acute and unnatural angle to the rest of her body. She also appears oblivious to the sounds of one of the surgeons chipping away at her thigh.

While she recounts her summer adventures, she is also undergoing a hip- replacement operation in a New York hospital and the surgery is being carried out under a local anaesthetic so she can be awake.

In American hospitals almost half of all operations are now carried out under local and regional anaesthetics like this, and in Scandinavia the figures are even higher, with eight out of 10 patients operated on using local anaesthesia.

But in Britain, it's estimated that less than 20 per cent of patients have a local anaesthetic, despite claims that those who are given them recover faster, are healthier, suffer less post-operative pain, and get back to work more quickly.

With a general anaesthetic, the patient is given a fast-acting drug, usually on the back of the hand, and is then maintained in a state of unconsciousness for the duration of the operation. Muscle relaxants may also be used to allow the surgeon to get at areas protected by strong muscles. When these relaxants are used, patients have to breathe with the help of a ventilator via a tube down the throat.

Local anaesthetics can be administered in the area where the surgery is to take place, or close to the large nerves that service the area to be operated on, like an injection around the collarbone to numb the hand.

Two other types of local or regional anaesthetic are spinal blocks and epidurals, which involve injections into different sections of the spinal cord. In both cases, once the drugs have been injected the area will become numb and feel paralysed, but the patient will remain awake and alert.

According to Dr Terry Dodge, a director of the American Association of Anaesthesiology, and an anaesthetist in South Carolina, this staying awake is one of the reasons why regional and local anaesthetics are so popular.

"Our population is very informed. They like to have as little done to them as they can, they like to know what is happening, and a lot of them like to be awake and alert. With regionals they have a shorter recovery time so they can get back to work and functioning, they feel like eating more quickly, their colour is a lot better, and they need less anti-pain medication.

"I'd say that in America 40 per cent have regionals and 60 per cent generals. That's a lot higher than the UK, and when I talk to British anaesthetists they are very surprised that we do so many spinal and local anaesthetics.''

A wide range of surgery is now carried out with regional anaesthetics at American hospitals, and only operations involving the head and chest are routinely performed with a general anaesthetic.

"Other than that, it's mostly regionals or locals. We do very few things on legs and arms with patients asleep. We do knee and hip replacements here under regional anaesthetics or epidurals. We remove colons and gall bladders in the same way and most of the patients are talking to me while it's happening. If patients are nervous they can be sedated, which makes the time go more quickly, but they can still scratch their nose if it itches.''

Just why there is such a big difference in practice between anaesthetists in Britain and those in America and a number of other countries is not clear. Some surgeons, particularly those who are young or inexperienced, are known not to like having patients watching what is happening, and some believe a general anaesthetic is less stressful for the patient. Anaesthetists say it's down to demand and that patients in Britain expect to be unconscious during their operation.

"One of the reasons for the different is patient expectation. There is something in the British psyche that says you must go to sleep during an operation and know nothing about it. Indeed, some people would find it stressful being awake. If you ask the average patient what state they would like to be in for a hip replacement, 100 per cent would say asleep,'' says Dr David Wilkinson, a consultant anaesthetist at St Bart's in London and the treasurer of the Association of Anaesthetists of Britain and Ireland.

Patients should be given a choice where possible, but if the anaesthetist is not skilled in the regular use of regional or local anaesthetics, it is an unrealistic option.

Dr Wilkinson says that patients' choices can also be influenced by what the anaesthetist tells them.

"You can influence the patient quite dramatically because there are two ways of putting things. I can say, 'You are going to have this operation on your knee, and I can either inject you with this big needle which I will push into your back and put in these drugs which will numb you from the waist down, or you can have a tiny little scratch on your hand which will put you to sleep.'

"But I could offer the same choice and say, "I'm going to make a tiny little scratch on your back and it will make you numb but you'll still be awake, or I can give you a general anaesthetic, push this great big tube down your throat and put you on a breathing machine for several hours. It's your choice.'''

He says 80 to 90 per cent of operations in the UK are carried out with general anaesthetics, and that there is no proof that regionals are better or safer: "Your discharge time is faster but long-term recovery probably doesn't change. You may be able to go home two days after having a bowel removed, but your body still has to recover at home,'' he says.

Although local anaesthetics are gaining in popularity, they are not new. The first nerve blocker was used in the spring of 1885 at the Johns Hopkins Hospital in Baltimore when cocaine was injected to anaesthetise a patient who was being treated for masturbation, then considered a grave medical problem.

It apparently did not work out for that particular problem but, within a short time, it was being used for almost every major operation. Survival rates increased dramatically, patients recovered very quickly, and the only casualties were members of the surgical team who became lifelong cocaine addicts.