4 ms·

We badly over-use general anesthesia. Next to antibiotics it might be the most over-used thing in medicine. When you scratch the surface of the neuroscience of

We badly over-use general anesthesia. Next to antibiotics it might be the most over-used thing in medicine. When you scratch the surface of the neuroscience of general anesthesia you will never want to experience it in your life if you can help it. It's effectively a controlled coma, and though we can control it, we don't know the precise mechanism of action. (Like so many things with the central nervous system it was discovered by trial-and-error.) If you're having a medical procedure and the physician mentions general anesthesia, always ask if IV sedation works as an alternative.

marvin 6y ago
Meanwhile, up here in Norway you have to beg and grovel and almost pretend to have a panic attack in order to get a one-off benzodiazepine-based IV sedative while taking a gastroscope down your throat. An acquaintance of mine with Down's syndrome, no less, couldn't do a gastroscopy to investigate a quality-of-life issue that was assumed to be benign, due to this. Boggles my mind, honestly. General anesthesia might be over-used, but some healthcare systems go too far in the other direction too.
- nlitened 6y ago
  I always had issues with gastroscopy (I guess mostly panic and uncontrollable reflexes), but recently I discovered that there’s an option to do it through nose instead of mouth (of course, with a thinner tube) — highly recommend it for people like me!
  - marvin 6y ago
    I've done the nose variety. Triggered my gag reflex like there was no tomorrow. Sounds like you are different, thankfully :)
- arcbyte 6y ago
  One of the vast number of reasons to prefer a nonsocialized Healthcare market: choice.
  - disgruntledphd2 6y ago
    Do you have other reasons, perchance?
  - tlamponi 6y ago
    Socialized healthcare systems often have room for a private sector, so you can have both. You can also go to other doctors in a socialized one, if their treatment (style) does not fit your cause. Also, in my experience there's lots of choice in most socialized health care systems. I had a gastroscopy in Austria, the Doctor asked me if I'd like a general anesthesia or rather a local, nerve blocker - mostly to avoid the gag reflex. He said that it may not be as pleasant without the anesthesia, but I still opted for it and am really glad I did. While it really was not pleasant, I was up and going again in about half an hour.
  - refurb 6y ago
    Nah... that has more to do with how medicine is practiced versus how it's paid for. I'd bet you'd have troubling finding any doctor willing to sedate for an endoscopy in that country. It's just "how it's done". Just like the US has it's own unique methods that seem odd to Europe.
  - marvin 6y ago
    Oh, you can do it privately instead. Costs $500 or so, but there's as much choice as the market allows for. My description was how it's normally done in the public system.
tibbydudeza 6y ago
Like Propofol ???. Don't it just turn on the chlorine tap on a neuron to open so that the voltage is now much lower and it will inhibit the signaling ???. It is the natural mechanism of a neuron so I don't see what side effects there could be - it is like pulling a jumper wire from one pin to another pin on a board to get a voltage right.
- jac241 6y ago
  Great point and I see that commenters above are suggesting conscious sedation (benzos) instead of general, which would probably be propofol in this case. Both benzos and propofol act at the same chloride channel...
  - sharru-in 6y ago
    I’m an emergency physician and we use all of the above medications with the exception of general anesthesia. Benzodiazepines are considerate anxiolytics whereas propofol would be considered moderate sedation. Neither of these require airway control (intubation) because people tend to keep breathing on their own and we really would much prefer that. With general anesthesia, you cannot protect your airway whatsoever and will need some form of airway control via either endotracheal intubation or LMA.
    - jac241 6y ago
      Thank you for the knowledge. I'm an M3 who hasn't had surgery, EM, or anesthesia rotations yet. Probably should have thought about the airway though...
    - seehafer 6y ago
      In most procedures I've observed (or experienced first-hand), a combo of Versed (a benzo) and a small amount of Propofol for the "milk of amnesia" effect is lumped under the term "conscious sedation". The patient is aware, can breathe on their own, and can respond to basic commands, but is relaxed, with a much higher pain threshold, and has no memory of the event. That sync with your experience, doc?
pge 6y ago
I had shoulder surgery a few years ago, and I had to argue with the doctor to get him to do a nerve block instead of general anesthesia. He never suggested it - I researched the options myself and found that patients who did the nerve block recovered faster and better, and yet right up until I rolled into surgery, the doctor was trying to convince me to do anesthesia. Sadly, I think the reason is that anesthesia makes patients easier to manage during surgery, which makes the doc’s job easier even if it is ultimately worse for the patient.
- refurb 6y ago
  Some of that is just inertia. Things are done a certain way and everyone is comfortable with it. Throw in a new method and everyone gets nervous. You might even have trouble finding an anesthesiologist who has done enough nerve blocks to be comfortable with it. And even if you do, your doctor has maybe never worked with them before.
TaupeRanger 6y ago
I'm not sure what you're trying to argue here. We don't know the "precise mechanism of action" of ANYTHING related to consciousness or subjective sensations. We don't even know why Tylenol works. That's not a reason to avoid it. For the overwhelming majority of patients, you simply fall asleep, avoid discomfort, and then go on with your life. Weighing that against the risks of a traumatic or very painful wakeful experience is not trivial.
- seehafer 6y ago
  I also steer people away from Tylenol and toward NSAIDs when possible because of the potential (though generally unlikely) risk of liver damage. What I'm trying to argue is that "one step away from death" is a state we too-often in American medicine treat as hum-drum.

marvin 6y ago

Meanwhile, up here in Norway you have to beg and grovel and almost pretend to have a panic attack in order to get a one-off benzodiazepine-based IV sedative while taking a gastroscope down your throat. An acquaintance of mine with Down's syndrome, no less, couldn't do a gastroscopy to investigate a quality-of-life issue that was assumed to be benign, due to this. Boggles my mind, honestly. General anesthesia might be over-used, but some healthcare systems go too far in the other direction too.

nlitened 6y ago
I always had issues with gastroscopy (I guess mostly panic and uncontrollable reflexes), but recently I discovered that there’s an option to do it through nose instead of mouth (of course, with a thinner tube) — highly recommend it for people like me!
- marvin 6y ago
  I've done the nose variety. Triggered my gag reflex like there was no tomorrow. Sounds like you are different, thankfully :)
arcbyte 6y ago
One of the vast number of reasons to prefer a nonsocialized Healthcare market: choice.
- disgruntledphd2 6y ago
  Do you have other reasons, perchance?
- tlamponi 6y ago
  Socialized healthcare systems often have room for a private sector, so you can have both. You can also go to other doctors in a socialized one, if their treatment (style) does not fit your cause. Also, in my experience there's lots of choice in most socialized health care systems. I had a gastroscopy in Austria, the Doctor asked me if I'd like a general anesthesia or rather a local, nerve blocker - mostly to avoid the gag reflex. He said that it may not be as pleasant without the anesthesia, but I still opted for it and am really glad I did. While it really was not pleasant, I was up and going again in about half an hour.
- refurb 6y ago
  Nah... that has more to do with how medicine is practiced versus how it's paid for. I'd bet you'd have troubling finding any doctor willing to sedate for an endoscopy in that country. It's just "how it's done". Just like the US has it's own unique methods that seem odd to Europe.
- marvin 6y ago
  Oh, you can do it privately instead. Costs $500 or so, but there's as much choice as the market allows for. My description was how it's normally done in the public system.

tibbydudeza 6y ago

Like Propofol ???. Don't it just turn on the chlorine tap on a neuron to open so that the voltage is now much lower and it will inhibit the signaling ???. It is the natural mechanism of a neuron so I don't see what side effects there could be - it is like pulling a jumper wire from one pin to another pin on a board to get a voltage right.

jac241 6y ago
Great point and I see that commenters above are suggesting conscious sedation (benzos) instead of general, which would probably be propofol in this case. Both benzos and propofol act at the same chloride channel...
- sharru-in 6y ago
  I’m an emergency physician and we use all of the above medications with the exception of general anesthesia. Benzodiazepines are considerate anxiolytics whereas propofol would be considered moderate sedation. Neither of these require airway control (intubation) because people tend to keep breathing on their own and we really would much prefer that. With general anesthesia, you cannot protect your airway whatsoever and will need some form of airway control via either endotracheal intubation or LMA.
  - jac241 6y ago
    Thank you for the knowledge. I'm an M3 who hasn't had surgery, EM, or anesthesia rotations yet. Probably should have thought about the airway though...
  - seehafer 6y ago
    In most procedures I've observed (or experienced first-hand), a combo of Versed (a benzo) and a small amount of Propofol for the "milk of amnesia" effect is lumped under the term "conscious sedation". The patient is aware, can breathe on their own, and can respond to basic commands, but is relaxed, with a much higher pain threshold, and has no memory of the event. That sync with your experience, doc?

pge 6y ago

I had shoulder surgery a few years ago, and I had to argue with the doctor to get him to do a nerve block instead of general anesthesia. He never suggested it - I researched the options myself and found that patients who did the nerve block recovered faster and better, and yet right up until I rolled into surgery, the doctor was trying to convince me to do anesthesia. Sadly, I think the reason is that anesthesia makes patients easier to manage during surgery, which makes the doc’s job easier even if it is ultimately worse for the patient.

refurb 6y ago
Some of that is just inertia. Things are done a certain way and everyone is comfortable with it. Throw in a new method and everyone gets nervous. You might even have trouble finding an anesthesiologist who has done enough nerve blocks to be comfortable with it. And even if you do, your doctor has maybe never worked with them before.

TaupeRanger 6y ago

I'm not sure what you're trying to argue here. We don't know the "precise mechanism of action" of ANYTHING related to consciousness or subjective sensations. We don't even know why Tylenol works. That's not a reason to avoid it. For the overwhelming majority of patients, you simply fall asleep, avoid discomfort, and then go on with your life. Weighing that against the risks of a traumatic or very painful wakeful experience is not trivial.

seehafer 6y ago
I also steer people away from Tylenol and toward NSAIDs when possible because of the potential (though generally unlikely) risk of liver damage. What I'm trying to argue is that "one step away from death" is a state we too-often in American medicine treat as hum-drum.