Anaesthetic Choices In A Post-Collapse World

Anaesthetics is a tricky business, monitoring the patients vital signs and maintaining their airway is a balancing act that requires knowledge of anatomy and physiology, as well as a huge amount of knowledge about the anaesthetic drugs available, and how they work in relation to muscle relaxants that are given to soften muscles allowing surgeons access without the twitching and reflex movements that would otherwise occur.

It would be stupid to think that post-collapse nobody is ever going to need an anaesthetic, of course they are, and for that reason knowing where the nearest doctor is, or better still having one in your group would be everyone’s number one choice. Sadly, not everyone is going to know where a doctor is, and few will be fortunate enough to have one in their group.

This article is not about you doing brain  surgery on the kitchen table, or digging bullets out of someone’s gut when a hunting trip goes wrong. It is simply to inform you of the choices available to you should you not be able to get qualified help.

The word anaesthesia means without feeling, and regardless of the form it takes that’s what an anaesthetic does, it prevents feeling. It does this either by numbing the nerve endings in the skin, as with topical anaesthetic applications and local anaesthetics and to some extent the use of ice.

Alcohol numbs the mind rather than the body and the degree of mind numbing dictates how much pain can be ignored.

General anaesthetics induce  narcosis..a controlled drug induced sleep that dulls the central nervous system.

Ice

We all know the feeling of numb feet after walking out through the snow and ice for too long. The application of an ice pack can numb an area enough for the purpose of carrying out minor precedes, such as the removal of a foreign body close to the surface. The problem with ice packs is they behave exactly as they do ‘in the wild’. They numb the exposed area but can also cause cold damage and frostbite. Ice should be applied in a wrap of some kind to minimise tissue damage, cling film/shrink wrap is ideal and won’t stick to the skin. In a grid down situation ice will be a problem unless it’s winter and you can get snow and/or ice from nature.

Alcohol

Most people know that alcohol can numb the body as well as the mind. On a personal level I have a very colourful tattoo that testifies to this fact, I have no idea where I had it done and I can honestly say I didn’t feel a thing!

Alcohol would not work for anything but mild trauma regardless of what the old westerns portray with bullets getting dug out after a few slugs of whiskey. It should be remembered that alcohol drops the body temperature and can cause major problems with anyone with any kind of liver problem. Just as an aside high proof alcohol can be used to sterilise equipment before using it in wounds.

Topical anaesthetics

These can be applied to the skin and cause the nerve endings in the skin to become numb. They often leave the skin with an odd texture and blanched white. Topical anaesthetics made for the skin are suitable to prevent the pain of injections and in a pinch could be used for very minimal procedures that barely penetrate the tissues under the skin.

There is another form of topical anaesthetic made for use on mucous membranes, that is the inside of the mouth. Care should be taken as using too much can impair the swallowing mechanism and lead to choking. These may be used on any mucosal membrane not just the mouth.

Local anaesthetics

Depending on where you are in the world these will have names such as lignocaine, lidocaine, bupivicaine, and amethocaine to name but a few. They are injected into the skin, and then further down into the underlying tissue layers producing a very decent effect that can facilitate quite major procedures.

These are, in my opinion, the drugs of choice for a post-collapse word. Onset of action is fast, the block is good and side effects are rare. It takes no particular skill to use them.

The needle in the first instance should be inserted at an oblique angle which means the delivery of the anaesthetic will be just under the skin. It will numb almost immediately. The needle can then be inserted a little deeper and so forth. The beauty of these drugs is that even an open would can be numbed providing instant pain relief and allowing further investigation. The patient remains conscious throughout avoiding the possiblity of airway management problems.

General anaesthetics 

Now we are getting into dangerous territory. In order to operate at a visceral level surgical muscle relaxation is required. This involves giving a drug that effectively paralyses the muscles to stop them moving and bunching up as surgery progresses. All of these muscle relaxants require the patient to be intubated and ventilated during the procedure. There is no way around this except to operate without giving a muscle relaxant.

Muscles will move and twitch and generally do there own thing if they are stimulated…this can be quite off putting to someone who has never seen it happen. In a nice clean modern operating theatre doing deep surgery without a muscle relaxant is not a option…we are however not talking about a nice clean situation here.

General anaesthetic can be facilitated using certain vapours that are picked up by carrier gases, oxygen and nitrous oxide and are then delivered via a circuit of tubes to the patient. Some of the most common anaesthetic vapours are Isoflurane,Desfluane,Sevoflurane, and Ethane. The delivery can be via a face mask, laryngeal mask airway or endo-tracheal tube. It’s a good reliable system of giving an anaesthetic but the specialist equipment would be hard to come by.

Ultimately the cylinders of carrier gases would run out and the method would no longer be viable as the vapours can’t be inhaled directly once unconsciousness has occurred. Anyone who has worked in an anaesthetic room where the exhaust system is sub-optimum will know how ‘fuzzy’ you feel in a short amount of time so we know that direct inhalation works but that’s with the vapours mixed with air, air has become the carrier gas. Direct inhalation of these vapours will most likely result in death.

Ether can render a person unconscious. A lint free cloth over the mouth and nose and the chemical dripped on will do it…if they don’t vomit first. If you do manage to get them unconscious without vomiting they will make up for it when coming around afterwards. Airway management is a must to protect from choking.

Chloraform produces a decent depth of anaesthesia but as with ether sickness is practically unavoidable. With both of these drugs the dose cannot be titrated. Airway management skills are a must when usuany ANY anaesthetic vapours.

 IV anaesthetic agents

IV anaesthetic agents are often referred to as induction agents…the induce narcosis. This sleep is a deep sleep from which the patient cannot be roused until the drug starts to wear off. Following induction, maintenance of anaesthesia is continued with one of the vapours mentioned previously.

It is entirely possible to conduct an entire anaesthetic by giving extra doses of the induction agent, each one given just before the previous dose wears off. It takes a good deal of experience to be able to pull this off and a pump that delivers the required milligram per kilogram dose would be the optimum way to do that.

Drugs such as Propofol, Sodium Pentothal Etomidate and ketamine are the more common induction agents. All except ketamine reduce the tonicity of the airway making it floppier and more difficult for the patient to maintain control of whilst they are unconscious.

With the exception of ketamine none of the drugs have an analgesic effect..they do not reduce pain.

None of the drugs except ketamine has an amnesic effect…ketamine can dull the memory of the incident leading to the anaesthetic. It also allows a measure of disassociation from the situation  the casualty finds themselves in.

Ketamine

Prior to 1963 Phencyclidine, PCP, was used as an anaesthetic agent. It was quite unpredictable and cause a majority of patients to awake with psychotic hallucinations after their operation. The drug was, like many, adapted to street use and was widely known as Angel Dust. In 1963 ketamine, which is chemically related to PCP was first synthesised. It has more reliable onset and duration times and although it can still cause hallucinations post-operatively they are far less severe. It is these properties that make it a desired street drug where it goes under various names such as Dorothy, special K, cat Valium, super acid and green, I am sure there are many more.

Ketamine is the only anaesthetic drug that has analgesic, hypnotic and amnesic  effects. It produces feelings of disassociation with events and surroundings. It also maintains the muscle tone of the airway, elevates blood pressure and heart rate and has a predictable onset and duration time. These features make it an excellent battlefield medicine and it is carried by  service medics as part of their standard kit. When given in sub-anaesthetic doses it provides excellent analgesia, comparable to that of high dose morphine but without the respiratory depression and decreased heart rates associated with opioid analgesics.

It is often the case that a sub-anaesthetic dose of ketamine is sufficient to facilitate a minor procedure, such as removal of shallow foreign body, suturing, or approximating a non-compound fracture. It is excellent for use in dressings application or changes and is a strong enough analgesic that cleaning contaminated or necrotic wounds would be far more comfortable for the patient, and less harrowing for the medic carrying out the procedure.

Ketamine is packaged in a clear glass multi dose vial in strengths of either 50 or 100mg/kg and hospital grade ketamine is usually in liquid form though in some parts of the world it comes as a powder for reconstitution with sterile water. It can be given iv but many doctors favour the intramuscular route, and this should definitely be the route used by anyone who is not used to the drug  as it provides a slower onset and longer duration of action.

In a hospital environment, with full back up anaesthetists would give a dose of  between 5-10 mg/kg to induce anaesthesia, giving another 3-5mg/kg approximately every 20 minutes to maintain the anaesthesia.

Sub-anaesthetic doses of 3-5 mg/kg would be given every 15 minutes in order to provide good analgesia levels for lesser procedures. In both these cases, using the intramuscular route of administration the onset time would be 15-25 minutes.

As mentioned patients may experience hallucinations on waking from ketamine. There is some evidence that asking the patients to think of non-exciting things such as walking through a field of flowers, or watching a sunset, when coupled with a quiet area during their recovery from the drug reduces the hallucinations by a considerable degree. I have had only one patient that has hallucinated during their recovery out of many dozens of ketamine anaesthetics I have assisted with.

Ketamine is a very useful and versatile drug but is should not be used in patients who are known to have ischaemic  heart disease as the increased heart rate caused by the drug can overload the heart and it is no use at all for removing foreign bodies from the eyes as it causes nystigmus, involuntary eye movements. It does cause an increase in salivation but this wears off quickly as the patient recovers. Care is always  taken to make sure that the patients head is not in a position where the tongue could fall back and block the airway, and that secretions can drain freely.

The detail provided in this article is for information only and is not a suggestion or recommendation that anyone but qualified medical practitioners with full hospital back up should use ketamine or any other drug for anaesthetic or analgesic or any other purpose whatsoever.

Take care

Lizzie