Not every medical breakthrough has its own movie. But the 1944 film "The Great Moment," by famed director Preston Sturges, memorializes the historic moment in 1846 when a New England physician gave the first successful public demonstration of a discovery that would revolutionize the art of surgery: the use of inhaled ether to temporarily render a patient unconscious while a tumor was removed from his neck. At the time, another New England physician decided that this breakthrough was so dramatic that it called for a brand new word — so he invented one. Oliver Wendell Holmes, probably better known today as a poet, coined the term "anesthesia," from the Greek roots an (without) and aesthetos (sensation). In the 160 years since, the practice of anesthesiology has not only become its own medical specialty, but has branched out into any number of subspecialties in fields ranging from intensive care medicine to pain management. "Even in the medical community, many people think that all we do is put people to sleep and wake them up," says Dr. Pam Varner, professor of anesthesiology at UAB, "but there's a lot more to it that that. You might say we're the medical internists of the operating room. "We handle all the various medical problems that arise in a very acute setting, in a finite period of time … that are sometimes exacerbated by what's going on with the surgery itself. Our patients are often dealing with concurrent problems, not just one. The use of laparoscopic and endoscopic surgical techniques has significantly improved recovery and has limited post-op problems, especially in sick patients. But interoperatively, they're much more difficult for us because they present very stressful positions, and sometimes have major physiologic effects. "We also care for patients in the acute postoperative period, which can be a somewhat high-risk time. The person is transitioning from a controlled environment and returning to the functions of breathing and consciousness. When we're assessing and monitoring them, it's important to know if a development is due to the anesthetic or whether something else is going on. So we do a lot of diagnosis in post-op." Varner didn't start out to be an anesthesiologist. Her first residency was in internal medicine, and her second was OB/GYN. "Even though I married an ob/gyn, I decided that was not my calling," Varner says. "I planned to go back into internal medicine, but part of the OB/GYN residency was two months in anesthesia, and I really, really liked it. "An anesthesiologist's typical day is always atypical and unpredictable. I liked the acuity, the fast interventional pace of it. The challenge of having to change plans in a split second. It can be dramatic and fast-moving. And one of the things I like best is that there's instant feedback. You can tell very quickly, for instance, that your intervention is effective." Dr. Art Boudreaux, professor and vice chair of anesthesiology at UAB, also lists the "instant gratification" as an aspect that influenced his choice of the specialty: "Anesthesiology is one of the broadest fields of medicine. We see patients of all ages and with all types of medical conditions. The procedural type things are fun to do, because you see instant results and can tell immediately whether you've done a good job or not — as compared to, say, treating someone for high blood pressure. You document the problem, put the patient on a medication, hope that he or she takes it properly, and then they return so you can see how they're doing. "By contrast, an anesthesiologist is there to take care of the patient during an intensive episode and protect them while they're having surgery. It can be nerve-wracking at times. But our goal is to minimize the danger to the greatest degree possible, so they can sail through the surgical experience comfortably, asleep, not having a lot of pain, and then treat any remaining issues postoperatively." Those intense experiences can also make for an intense schedule. A typical day for Boudreaux, who supervises resident physicians in anesthesiology and certified registered nurse anesthetists (CRNAs), begins at about 6:30 a.m. when he's assigned two or three operating rooms and goes back and forth to help the CRNAs and residents make medical decisions and monitor the course of the anesthetics. He's generally relieved by a partner sometime between 3 and 5 p.m. Though Boudreaux does most types of surgical cases with the exception of cardiac, he mainly concentrates on surgeries for head and neck cancers, which he says can be demanding for a number of reasons: "My expertise is in airway management. When we anesthetize someone, the drugs suppress their consciousness and depress their respiration, so we basically have to ventilate and breathe for them. With patients who have a cancerous growth in their mouth or neck that obscures or obstructs their breathing, it's often difficult to establish an airway. We may have to use local anesthesia, and place a fiber optic bronchoscope through their nose and into the airway before we put them to sleep." Varner's practice includes "a lot of neurosurgery, and I also work regularly in the outpatient surgery center and the pre-op assessment clinic. We all do trauma, from a simple fracture to massive multisystem injuries. It runs the whole gamut." In recent years, Varner says, the role of anesthesiologists has expanded into nonsurgical areas such as chronic pain management: "We offer a comprehensive evaluation, which can include unique, technically sophisticated, targeted regional anesthesia blocks that aid in both diagnosis as well as treatment." The increase in outpatient services in recent decades has changed the practice landscape for anesthesiologists, according to Varner, resulting in new and better drugs that are very short-acting so that patients are able to recover to the point that they can be taken home without an overnight stay. The impetus for companies to develop such drugs, she says, has meant great improvements for surgical patients in general, not just the outpatient variety. "It's also a case of 'have anesthesia, will travel,'" Varner says. "We're giving anesthesia in far-flung, remote locations that no one would have thought of years ago. Anesthesia is required regularly for diagnostic and interventional radiologic procedures. Other challenging locations include GI endoscopy labs and radiation therapy units. And in MRI scanners, for instance, where no metal can be used, we've had to develop new equipment such as ventilators and monitors that can work in these unusual environments. "Another big nonsurgical area is critical care medicine. Training requirements have been increased for all anesthesiology residents. A critical care anesthesiologist works with surgical teams in the trauma and surgical ICUs. Their focus on unique problems associated with injury, especially in patients with concurrent, chronic medical problems, has been demonstrated to improve outcomes." January 2007