Down the “K Hole"

Anesthesia is black box to most people.  The general public and even most medical professionals really don’t understand what truly takes place on our side of the drape in the operating room.  In order to explain the dark magic of “putting one to sleep” and more importantly waking a person up at the end of the case many analogies are employed.  Some describe the anesthetic process as flying an airplane with a stable cruising period in the middle with higher risk periods at take off and landing.  In a general sense this hold true as the beginning and end of anesthesia where the patient is being induced or emerging from anesthetic requires very close attention.  But the autopilot of general anesthesia also requires careful vigilance to the surgical process and changing conditions.  At any moment the anesthesiologist must be ready to adapt and intervene in a turbulent case of bleeding, breathing issues or blood pressure management. 

The soft touch down is achieved through a balanced approach to anesthetic depth, cardiac and respiratory physiology and pain management.  In another sense the anesthesiologist is somewhat like the chef or bartender of the medical world.  Through a variety of medications, monitoring and techniques the anesthesiologist must adapt the management of each the patient’s unique physiology to the surgical conditions.  

On a mission with MSF the ingredients and kitchen are rather different.  The medical conditions that patients present with are outside the usual clinical acumen. Malaria is endemic and is one of the first things to check for when someone spikes a fever.  The HIV rate necessitates suspicion of infection when a patient is losing weight or a wound isn’t healing.  Necrotising fasciitis is alive and well here with cases presenting in clusters every few days.  I’ve seen more gunshot wounds than in all my medical training though luckily they are usually limited to the limbs. 

Part of the motivation to participate in a mission such as this is to leave the comfort zone of my home practice and push the limits a little- to expand my envelope of experience.  In preparation for deployment on missions in austere environments I took a course on global outreach anesthesia as a resident. It was among the best four days of my entire medical training.  The course went through a variety of anesthesia equipment, monitors, medications and techniques that are relevant to working in the field.  As you move away from reliance on technology to support patient care, the basics of human physiology and clinical exam are once again emphasized. 

The primary anesthetic technique we use for most cases involving dressing changes, wounds, infections and burns is a deep intravenous sedation with a combination of medications common to anesthesia worldwide.  Midazolam, a benzodiazepine, is used as a relaxant and fentanyl, a potent opioid, is used for pain.   Both agents are short acting and an antidote to reverse the effects is readily available. 

The mainstay medication to provide general anesthesia is to induce a dissociative state with ketamine.  In plain terms, the patient is awake but unaware of their surroundings.  In some less than professional terms, a ketamine based anesthesia can be referred to as putting a patient into the “K-Hole.”  

Ketamine is undoubtedly the most valuable medication for anesthesia care in the developing world as it is a very affordable, powerful pain medication with a wide safety margin that avoids some of the side effects of other medications commonly used. Unlike many other anesthetic agents patients under the influence of ketamine maintain their respiratory drive to a much greater degree.   This means that is considerably more forgiving and can be administered more readily with less sophisticated monitoring by practitioners with less training.  In short it’s harder to overdose a patient on ketamine.  Back in Canada I use ketamine on a daily basis as part of a balanced anesthetic to treat pain but usually at about one tenth the dose to avoid potential unwanted hallucinatory side effects.

In some circles Ketamine is abused as a street drug.  Earlier this year at an international conference on the control of medications China proposed listing Ketamine as a schedule 1 narcotic on the same level as morphine or heroin.  In certain cultures ketamine has gained some popularity as a drug of abuse due to the hallucinatory effects.

The potential effects of increasing the control over ketamine could have severe implications for anesthesia worldwide.  The cost of this affordable medication would certainly rise and transport restrictions would create delays and shortages.   This may not cause much of a ripple back home but the impact on anesthetic care in low resource environments could be devastating, Canadian involvement in the lobby to prevent increased restrictions and access to this essential medicinewere temporarily successful but the risk of further restrictions remain.     

I am amazed at the effectiveness of a ketamine-based anesthetic but it remains rather challenging to compare the practice here in Central African Republic to home.  The patients here are extremely robust.  They tolerate painful procedures better than anyone back home.  I’m not going to change my home practice and start dropping patients in the “K Hole” at every opportunity but it is nice to know how to handle medications outside the usual Canadian practice.