Surgery, Anaesthesia & Emergency Care: The First Hour and the Operating Room

On 16 October 1846, in an operating theatre at Massachusetts General Hospital in Boston, a dentist named William Morton held a flask of ether to the face of a man named Gilbert Abbott while the surgeon John Collins Warren removed a tumour from his neck. The patient did not scream. Warren is reported to have told the crowded gallery, "Gentlemen, this is no humbug." The room is still called the Ether Dome.

Within months the news had crossed the Atlantic. Today the idea that an operation should be painless is so obvious that we forget that, for thousands of years, speed was the surgeon's chief skill. This piece explains what surgery and emergency care do and why; it is not medical advice and not a guide to doing anything. If someone needs help, call your local emergency number.

What surgery does, and what it costs

Surgery does five things: it removes (an inflamed appendix, a tumour), repairs (a broken bone, a torn artery), reconstructs, replaces (a joint, a kidney) or diverts (a bypass). All of them are a trade. The operation brings a certain, front-loaded risk (bleeding, infection, the anaesthetic) to avoid a risk that is spread over time (the disease). Whether it is worth it depends on how big each risk is and on what the person values. Surgeons call the choice of when, and whether, to operate indications, and some of the best surgical judgment is knowing when not to cut.

With a 2% yearly risk and a 3% operation risk, waiting has an 18.3% chance of harm by year 10, far above 3%, and the lines cross at 1.5 years. Drop the yearly risk to 0.3% and the lines cross after 10 years: for older or frailer people, a slow disease may never outrun the operation.

Asepsis and anaesthesia: the two revolutions

Before the 1840s, operations were fast because patients were awake; before the 1860s, many who survived the operation died of infection afterwards. Two advances changed both.

Anaesthesia. Not all of it began in Boston. Hanaoka Seishū in Japan operated on a 60-year-old woman for breast cancer on 13 October 1804 using a herbal mixture, tsūsensan. Crawford Long in Georgia removed a neck tumour under ether in 1842 but did not publish until 1849. Horace Wells tried nitrous oxide in 1844; his public demonstration in Boston failed. Morton's 1846 success was public and reproducible, and in 1847 the Edinburgh obstetrician James Young Simpson used chloroform. In 1853, John Snow, the same Snow of the pump, gave chloroform to Queen Victoria for the birth of her eighth child.

Asepsis. In 1847, at the Vienna General Hospital, Ignaz Semmelweis noticed that mothers delivered by doctors (who also did autopsies) died of childbed fever about 10% of the time, against under 4% in the midwives' clinic. He ordered handwashing in chlorinated lime, and deaths in the doctors' clinic fell from 18.3% in April to 2.2% in June. The common telling, a lone genius who was ignored and went mad, is too simple. He had no theory, published little for years, and the "cadaverous particles" idea was one of many; he died in 1865 in an asylum, from an infected wound, and the cause of his breakdown is still debated. In 1867 Joseph Lister, building on Pasteur's germ theory, published his method of treating wounds with carbolic acid. Antisepsis kills germs in the wound; asepsis, which followed (steam-sterilised instruments, gowns, and by about 1890 rubber gloves), keeps them out in the first place. Together with anaesthesia, they made long, careful operations possible.

A modern anaesthetic is not just "sleep". It aims at three things (the classic triad): unconsciousness, pain relief and muscle relaxation, each given by different drugs and each watched, with the anaesthetist's job being to keep the patient alive and stable while the surgeon works.

Watching the numbers: oxygen and the pulse oximeter

During an operation the patient cannot say how they feel, so numbers speak for them: heart rhythm, blood pressure, breathing, carbon dioxide breathed out, temperature, and oxygen. The oxygen number comes from the pulse oximeter, the clip on a finger. It shines red (660 nm) and infrared (940 nm) light through the tissue; blood rich in oxygen absorbs the two colours differently from blood poor in it, and the device reads the ratio at each pulse. Takuo Aoyagi and Michio Kishi built the first one at Nihon Kohden in 1972, and by 1987 it was part of the US standard of care for general anaesthesia.

The reading is a percentage saturation (SpO₂), but what matters is how much oxygen reaches the tissues. Haemoglobin loads oxygen along an S-shaped curve: the top of the curve is flat, the bottom is a cliff.

At a pressure of 100 mmHg and haemoglobin 15 the saturation is 97% and about 990 mL of oxygen are delivered each minute. Fall to 60 mmHg and saturation is still 90%; fall to 40 and it is 75%. Because the top is flat, the reading hardly moves at first and then drops fast. Drop haemoglobin to 8 and saturation still reads 97% while delivery falls to about 540 mL a minute: the number on the clip is not the whole story. Pulse oximeters also have known limits: they can over-read in people with darker skin, be fooled by carbon monoxide, and fail with movement or poor circulation.

The checklist and the Swiss cheese

Most surgical harm is not a dramatic slip but a gap: the wrong side marked, an antibiotic not given, a swab left behind, an instrument missing. The psychologist James Reason's "Swiss cheese" picture (1990) describes this: every defence has holes; harm happens only when the holes in several slices line up.

In 2008 WHO launched a Surgical Safety Checklist of about 19 items, read aloud at three pauses (before anaesthesia, before the first cut, before leaving the room). In 2009 Alex Haynes and colleagues published a study in the New England Journal of Medicine across eight hospitals in eight cities (Toronto, New Delhi, Amman, Auckland, Manila, Ifakara, London, Seattle). After the checklist, major complications among inpatients fell from 11.0% to 7.0% and deaths from 1.5% to 0.8%. It was a before-and-after study with no control group, and later work was mixed: a 2014 study of Ontario hospitals found no significant change after a checklist was required. Evidence suggests that how a checklist is used, with real pauses and a team willing to speak up, matters more than the paper.

With 10 errors in 1,000 operations and three layers that each catch 60%, only 0.64 get through if the layers are independent. But if 10% of errors are of a kind every layer misses (the same blind spot, the same tired people), the figure is 1.58. More layers do little once the shared blind spot dominates, which is the real argument for a culture where anyone may stop the line.

Trauma and the golden hour

Injury is a leading cause of death for the young worldwide, and care begins before the hospital. A trauma system links the roadside, ambulance, a hospital with the right resources, and rehabilitation. One idea has dominated: the golden hour, which says that the first hour after major injury decides survival. R Adams Cowley, who built the shock-trauma centre in Baltimore, popularised it, and it has shaped ambulance targets worldwide.

The evidence is mixed, and that is the honest account. A 2001 review by Lerner and Moscati, "The golden hour: scientific fact or medical urban legend?", found no scientific basis for a magic 60 minutes. A 2010 US cohort of 3,656 injured people (Newgard and colleagues) found no association between ambulance times and death, though critics note most patients were reached in under an hour, so it could not test the idea well. And in the US military, after a 2009 order to evacuate critically injured casualties within 60 minutes, median transport time in Afghanistan fell from 90 to 43 minutes and the share reaching a hospital within the hour rose from 24.8% to 75.2%; the study (Kotwal and colleagues, 2015) reported fewer deaths, partly from a modelled projection. The usual reading is that time is critical for people who are bleeding fast, and a clock is a poor stand-in for the condition: get the bleeding stopped, get the person to definitive care.

For a 70 kg adult with about 4.9 litres of blood, a loss of 100 mL a minute reaches 15% in under 8 minutes and 40% in about 20. At 1,000 mL a minute, it is two minutes. At 10 mL a minute it takes more than 3 hours. The same "hour" can be far too long or comfortably long; that is the contested part.

Triage, CPR and the first minutes

Triage, from the French trier, to sort, means treating people in order of need and chance to benefit, not arrival. Baron Dominique-Jean Larrey, Napoleon's chief surgeon, argued for it on the battlefield and introduced his "flying ambulances". Emergency departments use five-level scales such as the Emergency Severity Index (developed in 1998); in disasters, simple systems such as START (Newport Beach, 1983) sort casualties into immediate (red), delayed (yellow), minor (green) and expectant (black). Triage is imperfect; reviews report under-triage in a third of some hospital cohorts, and critics say colour tags have not been shown to predict survival accurately.

With the starting settings the load is about 85%. In a first-come queue everyone waits about 35 minutes; under triage level 1 patients are seen in about 7 minutes, and level 5 patients wait about two hours. That is the price, and the point.

The first minutes of a cardiac arrest, when the heart stops pumping, follow the same logic. At awareness level, current guidance from the main resuscitation councils (ILCOR, the American Heart Association, the European Resuscitation Council) asks a bystander to do three things: call the emergency number, push hard and fast in the centre of the chest, and use an automated external defibrillator (AED) as soon as one arrives, following its voice instructions. An AED analyses the heart rhythm itself and only advises a shock when one is needed. The usual target is 100 to 120 compressions a minute, a little over 5 cm deep in an adult. Survival from cardiac arrest outside hospital is low: one US registry summary from 2018 found about 10% survived to discharge overall, and about 35% when a bystander used an AED. Please take a certified first-aid course; this page is not training.

Surgery for everyone: global access

Surgery is not a luxury of rich countries; it is a part of care for injury, childbirth, appendicitis, cleft lip and cataract. But the Lancet Commission on Global Surgery (2015) estimated that five billion people lacked access to safe, affordable surgical and anaesthesia care when needed, and that 143 million additional procedures a year were needed in low- and middle-income countries. The shortages are of people (surgeons, anaesthetists, nurses), equipment (oxygen, working pulse oximeters), and money, since a family may be bankrupted by an operation.

Several answers have been tried. Charities such as Lifebox have supplied pulse oximeters to operating theatres that lacked them. Task-sharing lets trained non-physician clinicians do some procedures, as with surgical technicians who perform caesarean sections in parts of Mozambique. The WHO checklist is free. None of these replaces the main need: reliable oxygen, electricity, blood and trained teams, and health systems built so that surgery is part of the plan (see Public & Global Health, 35/61).

What a graduate just sees

• An operation is a bet: a certain, front-loaded risk against a spread-out one.
• Infection is controlled by keeping germs out, not just killing them in the wound.
• Under anaesthesia the monitors are the patient's voice; read each number for what it measures and what it misses.
• The oxygen curve is flat at the top and steep at the bottom, and haemoglobin matters as much as saturation.
• Safety is layers with holes; checklists work when the team actually pauses and speaks up.
• For trauma, ask about the bleeding rate, not the clock alone.
• Triage trades fairness-by-arrival for fairness-by-need; someone always waits longer.
• For a cardiac arrest: call, push, shock, and learn it properly beforehand.
• Most people on Earth cannot get a safe operation when they need one.

Where it shows up next

• Anatomy (35/54) and Pharmacology (35/56) sit under every step: where to cut, how drugs act.
• Physiology (35/49): blood volume, oxygen delivery and shock.
• Medical Ethics & Law (35/60): consent for emergencies, and who may be treated first.
• Public & Global Health (35/61): injury prevention, ambulance systems, and surgical access.
• In the world: operating theatres, ambulances and helicopters, emergency departments, disaster response, and every shopping-centre AED.

If you want to go deeper

• 📘 Textbook. Bailey & Love's Short Practice of Surgery (CRC Press). A standard UK and Commonwealth undergraduate text.
• 📘 Textbook. Sabiston Textbook of Surgery (Elsevier), and for anaesthesia Miller's Anesthesia (Elsevier), the reference works.
• 📘 Gentler. Atul Gawande, Complications (2002) and The Checklist Manifesto (2009); Lindsey Fitzharris, The Butchering Art (2017), the story of Lister.
• 🌐 Free resources. WHO's Safe Surgery pages and the free courses at OpenWHO. For first aid, take a certified course from the Red Cross or a national resuscitation council.