Confidence is a strange creature. It lives somewhere deep in the woods of all our fears and insecurities, and only emerges when we are absolutely certain everything is going to be alright. So, when it comes to the idea of surgery, where some surgeon is going to be standing over us with his or her arms inside our bodies with a saw, most of us prefer total unconsciousness from well before the operation until well after it. No-one in the West would accept the practice of acupuncture where, with a few needles sticking in our head and left big toe, we are able to chat with the surgeon about the latest episode of “Lost”. General anesthetic is the desired norm. For some reason, our culture prefers to protect the mind from all conscious knowledge of what is going on during the procedure and from the pain caused by the surgery. The latter is usually produced by the intravenous administration of one of the strongest painkillers. The problem with this approach is that the combination of general anesthesia with intravenous drugs is most likely to produce nausea and vomiting. If the use of painkillers goes on for any length of time, it also causes the bowels to slow down and grow uncomfortable.
For the last ten years, the Mayo Clinic has been pioneering a different approach for hip or knee replacement surgery. Rather than simply knocking people out, surgeons now start by administering painkillers for a day or more before the operation. Using pills to build up the concentration of painkiller in the blood stream before the operation has two beneficial effects: patients feel less pain during the surgery and have none of the side effects associated with intravenous administration after surgery. Secondly, the patients are given sedatives before the operation. This calms the mind and reduces the need for a general anesthetic. Indeed, most surgery is now performed either using a nerve block which numbs the immediate area around the hip or knee joint, or regional anesthetic which only affects the lower half of the body. The majority of patients report less pain following localized anesthetic and only require the use of milder painkillers like tramadol during the recovery phase. People are also able to regain mobility more quickly, getting out of bed one or two days earlier than following a general anesthetic. This approach also expands the number of people able to undergo surgery. Many people who are either overweight or older are refused general anesthetic because their breathing or heart action is weak.
In some senses, this is dramatic news. Instead of that awful feeling of disorientation and nausea following a general anesthetic, people are recovering faster and going into physical therapy earlier to get their limbs moving again. This is a significant improvement. Indeed, just consider the difference in the choice of painkillers. Under the old protocol, the strongest painkillers would be administered intravenously. Today, people are going through the whole procedure using only tramadol. This is not to deny the use of the stronger opiate drugs. But it gives patients a choice and avoids any potential problems with dependence. Whether this new approach will roll out across the whole of the hospital service is speculative. People can be talked into this because they have greater confidence in the Mayo Clinic. Whether their confidence will be so high in a local hospital is more difficult to predict. All we can say is that fear of pain is a big motivator.