Being an anaesthetist has taught me the power of patients" last words

Every so often, as an anaesthetist, you know the patient may not wake up and that you will be the last person they ever speak to. This operation may be their last chance at survival but it may also be the very instrument which ends their life. Something has ruptured. They may be bleeding. You don’t know if you can “turn off the tap”. The patient may be frail but you must at least give them the chance.

Getting them through the operation can be the easy part but the body has suffered enough and simply does not have the reserve to deal with the trauma. They remain sedated as the feeling of a breathing tube and the nature of being a patient in intensive care would be as unpleasant as the operation itself. You keep them alive but only under the immense power of an arsenal of drugs reserved for these circumstances. You keep them alive with the hope they may pull through, but occasionally only so their loved ones can be by their side at the moment of passing.

Barriers may unintentionally fall and their true feelings are revealed, possibly followed by a knowing laugh

A patient’s last words can be deeply profound, even prophetic of their own mortality. They can be completely ignorant of their condition through delirium or dementia. Vital organs only take minutes to become irreversibly damaged. They need oxygen, they need blood and the body’s systems are failing, often before your eyes. Sudden confusion, unconsciousness, abnormal breathing, all signs of impending shutdown. You have to take over, you have to replace that which has failed. A tube to deliver life-sustaining oxygen, fluids or blood to replenish what was lost, and anaesthesia to rest a frantic brain and spare the memory of any suffering.

Those who you can talk to you reassure. You tell them everything will be done to wake them and that there will be no pain, they will not suffer. They understand. Reassurance is easy, a few simple words spoken honestly and calmly. You gauge the mood and ask them about who is waiting for them when they awaken. How long have you been married? What kind of dog do you have? Find the right path to follow and they will lead you down a road of conversation which lasts until the point of unconsciousness. Barriers may unintentionally fall and their true feelings are revealed, possibly followed by a knowing laugh. They know their secrets are safe.

Revelations range from patients, previously brave-faced, who confess their terror at the prospect of never waking, to those who divulge a sense of abandonment of life. They have suffered enough and want this sleep to guide them gently to death. One patient admitted to having enjoyed a cheeky slug of whisky a friend had smuggled to him just before coming to theatre. People share a joke and a smile. The release of a smile is echoed in the slowing heart rate only associated with feeling calm and relaxed. The beeping machine that monitors their heart becomes a metronome of their emotion.

I remember one man who was brought to theatre for an emergency operation. He was dying but nobody knew when. The cancer had spread and was now blocking his gut. He knew the operation might kill him but wanted to take the chance that he may survive long enough to leave hospital to organise his affairs and be with his loved ones at the end. His mood struck us all. He was dying yet had a smile on his face and was quick to share a joke. No one said “see you afterwards” as we most often do, we just invited him to think of somewhere he would rather be. He smiled again – “anywhere but here” – and laughed. He never spoke again. He passed away under anaesthesia the following day with his family by his side.

Only in the hours or days following the event does the poignancy hit you. You start to reflect on not only the words themselves but the underlying emotions the patient was experiencing. There is a sadness, especially when speaking to a patient’s loved ones, but the opportunity to reflect provides a chance to learn and question your own practice. Your normal bedside manner was aimed at inducing calm before the anaesthesia itself. Did it work? Did you quell the fear in any way? Could anything have been said differently or not at all?

A person’s last words can be a defining moment. You speak to families and you tell them there was a smile, even a giggle. The fact that this was their last conscious, communicated thought will hold in the memory of anyone who cared for them. “Yep, that sounds like him!” Another smile. A seemingly impossible moment of happiness.

If you would like to write a blogpost for Views from the NHS frontline, read our guidelines and get in touch by emailing sarah.johnson@theguardian.com.

Join the Healthcare Professionals Network to read more pieces like this. And follow us on Twitter (@GdnHealthcare) to keep up with the latest healthcare news and views.

Being an anaesthetist has taught me the power of patients" last words

The secret life of an anaesthetist: if surgeons are the blood, we are the brains

You have to get used to being invisible as an anaesthetist. A large percentage of the public has no idea that we’re medically qualified. I’ve been asked how many GCSEs you need to be an anaesthetist. In fact our training is as long as that of a surgeon. It takes seven years of specialist studies after you’ve already completed two years of basic general training; and that’s after five or six years at medical school.

Patients always remember the name of their surgeon, never that of their anaesthetist. But it’s still a hugely rewarding job. We’re everywhere in the hospital. In theatre obviously, but also in intensive care, on the wards, in the emergency department, and in the pain clinic, with those who are really suffering. We assess people’s fitness for surgery, how likely they are to suffer complications, and support them through the operation itself and into the postoperative period.

If there’s an emergency during an operation the team looks to the anaesthetist for leadership. If you panic, it spreads

When you first start anaesthetising patients early on in your career it’s terrifying. You know that if you get it wrong you might kill someone. Our drugs stop people breathing and it’s our job to take over that function. Even after nine years I still get a frisson of nerves in some situations. I hide it though; it’s an important part of the job to stay calm at all times. If there’s an emergency during an operation the team looks to the anaesthetist for leadership, as the surgeon is often too focused on fixing the immediate problem. If you panic, it spreads and the team loses the ability to function efficiently.

Anaesthesia is a very safety-oriented speciality; we’ve led the way in reducing patient harm by looking at human factors, using simulation training and reporting “near misses”. By sharing episodes where a patient has nearly come to harm, we hope to address the causes and prevent actual harm from occurring in the future. We’ve embraced ideas from aviation and other high-reliability industries about how a team functions effectively. We try to flatten the hierarchy in theatre so that the least qualified individual can raise concerns without feeling intimidated. This makes it especially frustrating when patients come to harm after they leave your care because the rest of the system is struggling to cope.

There are so many gaps in rotas of doctors, nurses and the wider healthcare team, and the proposed junior doctor contract changes will only make this worse. The outlook for patients who suffer complications after surgery is determined not by the presence of the complication, but by how quickly it is picked up and dealt with. This simply can’t happen when workloads are too high.

I look after one patient at a time. This ability to offer a premium level of care is one of the reasons I became an anaesthetist in the first place. On the wards each doctor will be responsible for up to 30 people a day, and even more at night. I can see with each heartbeat what the patient’s blood pressure is in the operating theatre; on the wards, it might only be checked once every four hours.

The speciality is a broad church, so there is room for all personality types. But given the precision involved there is perhaps a tendency to obsessive traits. I’ve worked with colleagues who have a 10-minute ritual for putting in an intravenous cannula that had to be completed in the correct sequence. Our postgraduate exams are renowned for being tricky but they are really a test of commitment. We’re experts in physiology, pharmacology, and physics; we have to know about everything from cellular respiration to how our drugs work, to the internal workings of a defibrillator.

Patients are usually nervous when they arrive in my anaesthetic room. It’s an exercise in trust to place your whole life in the hands of others. Every anaesthetist will have their spiel, some small talk to distract the patient from their imminent surgery. I ask them about family, talk about their favourite place to visit, what they do for a living. I modify my “going to sleep” talk depending on the small talk that’s gone before. If they love travelling, I’ll talk about a white sandy beach, with crystal clear waters, a gentle breeze. The more nervous they are, the longer they take to go to sleep. Many young, usually male, patients have commented as the drugs take effect that it feels just like a Saturday night. I’ve also been asked if I liked to have sex in a vest – I decided not to pursue what he meant by that when he woke up.

Every anaesthetist has a secret weapon when working in the operating theatre. We always work with an assistant, who might be a nurse or an operating department practitioner (ODP). The very best of them could do my job without thinking twice, but they choose even greater anonymity than the anaesthetist enjoys. Many a time I’ve had my bacon saved by an astute ODP. Some appear to have powers of extrasensory perception; I turn to ask for something and there it is in my hand.

I’ve also worked with many theatre colleagues with a wicked sense of humour. Before my first unsupervised operating shift, I confessed to the ODP that I’d never worked alone before. He paused and stuttered that neither had he, it was his first day at work, being newly qualified. I spent the entire day terrified that some disaster would befall us, and we wouldn’t be up to the challenge. At the end of the day he came clean – he’d been doing the job for 20 years.

Frustrations creep in to the job when the system fails. I often arrive at 7.30am (30 minutes before my shift begins), so I can find space on the pre-op ward to see my patients in private, find out their history and take the time to address any concerns. It’s then immensely distressing when operations are cancelled due to lack of beds, or lack of notes, or the surgeon’s been double booked, or you are moved to another job at short notice. Anaesthesia can also become routine; it’s a far cry from the early days of the speciality when unpredictable drugs were used without monitoring. If the patient is fit, it’s rare for them to come to harm from a general anaesthetic.

It is important to have other interests to distract from the stresses, strains and occasional boredom of the job. In my spare time I’m a volunteer doctor for the ambulance service. Being under a car in a ditch in the rain at 2am is very different from the bright lights of the operating theatre. Some of my colleagues are real polymaths. There are painters, musicians, novelists, as well as some quite serious sports people. The coffee room in the morning is the preserve of the middle-aged man in lycra. We see every day the damaging effects of too little aerobic fitness, so we’re staving off our own mortality.

The best bits? Reassuring nervous patients, rendering labouring women pain-free with the magic of epidural analgesia and, of course, merciless surgeon baiting. I’ll ask if they need me to Google instructions for the operation, or if they’ll be finished before new year. We say there’s a blood-brain barrier between the surgeon and the anaesthetist: they’re the blood, and we’re the brains.

• Are you a private tutor, a plumber or a mental health nurse? We want to hear your candid accounts of what work is really like. Find full details on submitting your story anonymously here

The secret life of an anaesthetist: if surgeons are the blood, we are the brains