HF8241 Threshold. 1969, Length: 00:25:33, B/W, Sound. This Beta SP was duplicated from a 16 mm answer print by BonoLabs 

for the National Library of Medicine, April 2014.

[...]

[8,7,6,5,4,3,2]

[Waves crashing]

[Doctor:] Are you from anesthesia? [Anesthesiologist:] Yes.

[Doctor:] This boy apparently was in some sort of...near Ocean Point. I thought you might know something about salt-water drowning.

[Anesthesiologist:]  Right, from animal research studies, in salt-water drowning you have water and plasma pouring 

out of the blood into the lung, which makes the problem worse.

[Patient gasping for air]

[Anesthesiologist:] We're having trouble.

[Doctor:] I think he's just obstructed the upper airway, which is certainly one problem that goes on 

and we must move now quickly to the intensive care unit where we can provide monitoring. 

We'll have to get blood gasses, central venous...

[Anesthesiologist:] There's a difference in treatment between saltwater and freshwater. Anesthesiology research.

[Typewriter keys clacking.]

[Threshold]

[Narrator:] It's not easy, this anesthesiology story. Patients here, research there. 

Now, if we could emphasize patient cares related to research.

[Emily:] I don't think we made that point well enough.

[Doctor:] Emily, you'll be the death of this office.

[Emily:] Not true. I was having a dinner party and we got on this subject and everyone was fascinated. 

You know, they never really thought much about it, sleep and pain.

[Doctor:] That's why we're doing the article.

[Emily:] I want to see.

[Anesthesiologist:] More. A little more, little more, don't stop, more, more, more, more. Okay, now relax. That's fine.

[Doctor:] I have a few questions. Do we know what he's doing?

[Anesthesiologist:] Now, I don't know what Dr. Smith thinks he's breathing right now, 

but I suspect he thinks he's breathing carbon dioxide and he isn't.

[Emily:] Have you tried it yourselves?

[Anesthesiologist:] Yes, everything we've done up here, we've all experienced ourselves before we've done it to any patients.

[Emily:] What do you learn from it?

[Anesthesiologist 2:]  Okay, let's pull out the other way.

With this apparatus we're studying the effects of slight increases in aspired carbon dioxide, 

which fool the brain into thinking the body's working hard, so we overbreathe. 

We're not studying hypoxia at the moment.

[Emily:] What's hypoxia?

[Anesthesiologist 2:] Hypoxia is less oxygen than normal. 

You get hypoxic, moderately hypoxic on the top of Pike's Peak.

[Doctor:] Pass out. 

[Anesthesiologist 3:]  Well, I wouldn't say so.

[Interviewer:] Could you define unconsciousness?

[Anesthesiologist:] What is it? Nobody knows. Nobody knows what keeps you awake right now, 

and how anesthetics put you to sleep.

[Anesthesiologist:] We do not understand what anesthesiology is all about, we don't understand the state of anesthesia.

[Anesthesiologist 2:] Well, yes, even now after 20 years and seeing a patient go to sleep every morning 

and injecting a drug that completely paralyzes them, it's an aweing experience. 

I was on airplane last night and one woman didn't want to hear anything 

about the fact that this man had all our lives in his hands really. 

I sort of felt, well, I'll be very happy when we land in Philadelphia. 

I think people feel the same way about anesthesia and that you tinkered with a very significant part of their brain, for example.

[Anesthesiologist 4:]  Right. Eventually some chemical reaction must take place, 

which turns something off or turns something on or changes something. 

Not a cellular level, but the molecular level. 

How does it do what it is doing? 

And that's related to this shape that the molecule will assume in the body.

[Interviewer:] What do you mean, shape?

[Anesthesiologist 4:] Will it occupy this particular shape or indeed will it occupy this one? 

Literally nobody knows, 

at a molecular level now, what's going on and what those anesthetic agents do. 

What we're really talking about is the function of the human brain.

[Anesthesiologist:] What's going on inside, how the anesthetics change what's going on.

[Interviewer:] Do volunteers understand what's going to happen?

[Anesthesiologist:] We show them a study actually in progress. 

And we'll say, "This is what you will look like, you will be on that table." 

And a great many number of these people are willing to do it.

[Emily:] There are people who like to be right up against a problem.

[Interviewer:] How does it feel?

[Anesthesiologist:] Stewart will feel numbness and tingling, the sounds will become louder, he's spinning down a long corridor. 

Dr. Nae himself has breathed this mixture and knows exactly what these feelings are.

[Nurse:] 15 seconds to sample three.

[Interviewer:] It's a countdown?

[Anesthesiologist:] When the countdown reaches zero, radioactive krypton is suddenly switched into the breathing system.

[Interviewer 2:] Is that a radioactive tracer?

[Anesthesiologist:] Yes. The krypton emits small amounts of radioactivity, which tell us how much energy his brain cells are producing.

[Interviewer 2:] So, what do you think you'll be working on next?

[Anesthesiologist:] We would bring this massive amount of equipment into the operating room. 

We've now been able to identify rather special problems in anesthesiology and we see that these traditional drugs really don't fit.

[Dr. Nae:] Yes, since the days of chloroform, about 20 additional anesthetics have been given. 

So powerful that we've got to know from second to second the exact concentration that the patient's breathing. 

We found recently that as soon as he went to sleep, his oxygen fell. 

In essence, it's due to the anesthetic drugs, and we take constant sampling. 

What we've done is to establish a laboratory right in the middle of an operating suite. 

This brings research techniques in a daily availability so far as patients are concerned.

[Interviewer 2:] This is one reason you're in it?

[Anesthesiologist:] Oh it certainly is, the notion that anesthesia is something that can be improved.

[Interviewer:] What about how anesthesia used to be?

[Anesthesiologist:] Paradoxical as it may sound, the attitude just 15 years ago was that this was 

a fairly simple procedure which could be carried out by our dumbest intern or a technician for that matter. 

Being dumped into anesthesia under those circumstances, not really knowing any more, 

any less than that of the rest of the people, horrified me so much that I think it had something to do 

with influencing me towards getting into the specialty myself.

[Doctor:] Anesthetists have an extraordinary advantage than, you see, to study man and to find out ways of relieving his various symptoms.

[Dr. Nae:] In the clinical situation is where you get the ideas for your next research project. 

It has a unique feedback in that you can go back to the laboratory with a host of ideas, not only for what is interesting to study next, 

but also about what is important to study next. 

The need for new agents usually arises from one's bedside experience.

[Doctor:] Yes, the interactions that occur in patients between the medicines, drugs, and other chemicals 

that they take in this rather frenetic world in which we live and how these drugs interact with anesthetics.

[Anesthesiologist:]  You know really, when you're anesthetized, that simply is not enough. 

A surgeon requires a great deal more than that in taking care of people. 

One you can see, gee, if I had a drug like this that would be just what he would need. 

And the next step is to go to an organic chemist, say, "Hey, can it be made?" 

Once we get the drug we have to test it. 

And it gives us particular insight into the mechanism of action.

We then study these things in animals. 

The animal is anesthetized and we record the movements of the muscles based on the stimulation of the nerves. 

So, you can see then the decrease in muscle activity as a result of this drug. 

You can see the twitch now recovering. The drug is wearing off.

[Emily:] It isn't just research. There you are with a person and you have to do something.

[Anesthesiologist:] Oh, yes. The nerve stimulator that we use in the laboratory 

has spawned the Block-Aid monitor that we use in the operating room.

This allows us then to monitor this particular drug, 

so we can have some idea as to the profoundness of the effect and the time scale as to when it is beginning to wear off. 

And that's very important in anesthesia. 

Because you are different from anybody else ever created. 

Each drug, therefore, may well have a different effect on you as a different entity from him.

[Interviewer:] And children?

[Anesthesiologist:] One of the erroneous concepts, I think, in terms, or at least in the minds of most laymen, 

is that a child is a miniature adult, 

and nothing could be further from the truth.

[Interviewer:] Do you give a different dose?

[Anesthesiologist:] With some muscle relaxers I might give them a larger one. 

As a matter of fact, if we used that same amount of anesthetic on a weight basis and gave it to you, you would be dead.

[Interviewer:] Well, what kind of operations do you have to do on children?

[Anesthesiologist:] Well, sometimes the arteries will wrap around the air passages and constrict them. 

Sometimes the spine is born open and this has to be closed immediately to prevent infection.

[Emily:] On the first day?

[Anesthesiologist:] On the first day of life, yes.

[Emily:] I can't image that. A first day baby.

[Interviewer:] It's like my brother's child, they didn't dare operate.

[Anesthesiologist:] Yes, pediatric surgery is a relatively new form of surgery. 

It's only been since the early 1940s that major operations have been performed with success on infants. 

Concentrating on supporting the patient's life systems.

[Interviewer:] You're practically breathing for him.

[Anesthesiologist:] Yes, understanding how he's breathing and understanding how his heart is beating or his brain is functioning.

[Emily:] It isn't just putting him under.

[Anesthesiologist 4:] Well, it became very clear to me, very soon after I began to do anesthesia, 

that preventing pain and putting the patient to sleep was only a small part of what an anesthesiologist did... 

that a great deal of what he did was keeping the patient alive during a very critical period in the patient's life, 

the two, three, four hours that he was being operated on.

[Interviewer:] Well, what about people outside of surgery?

[Anesthesiologist 4:] We began to be called into handle patients who weren't being operated on, but who needed this intensive kind of care.

[Interviewer:] It's all part of the same thing.

[Anesthesiologist 4:] It isn't different. That's the point that I like to get across.

[Interviewer:] What would put people into intensive care besides surgery?

[Anesthesiologist:] Well, you have the traffic injury, you have certain neuromuscular diseases and emphysema, chronic bronchitis, 

many of the patients with heart failure. 

Pointing out that you cannot separate the function of the heart and the function of the lung. 

And the thing is, that if you can breathe for such an individual...

[Doctor:] The crucial thing about breathing is that you have no reserves for oxygen at all and so that your, 

the minute you stop breathing your brain becomes inoperable due to lack of oxygen and dies in a matter of minutes.

[Dr. Nae:] Yes, very recently we had a more old-fashioned type of chest injury. 

A farmer was charged by his bull and he was unable to breathe for himself.

[Interviewer:] Getting better?

[Farmer:] Yes, much.

[Interviewer:] Your jaws are still wired together?

[Farmer:] Yes.

[Interviewer:] What was the last thing that you remember about the bull?

[Farmer:] He started shaking his head.

[Interviewer:] How did you feel when you woke up?

[Farmer:] I was awful thirsty.

[Interviewer:] Did you feel alone?

[Farmer:] No. Not a bit, because there's always somebody right there.

[Anesthesiologist 4:] I think the most immediately striking thing about any intensive care unit is that it contrasts with 

the notion that most people have about a hospital.

[Interviewer:] It looks anything but restful.

[Anesthesiologist 4:] Yes. You don't see a quiet comfortable bedroom with nurses quietly moving around. 

It's the kind of place where nurses and physicians are living with a patient and treating the patient 

on a moment to moment basis, and that means that the place is equally active at 12 noon or at 12 midnight.

[Surgeon:] Boop, boop, boop, boop, boop, boop.

I was only gone a second. 

We just operated on him a week ago. He was in, he's been in there three weeks. [Interviewer:] Thomas?

[Surgeon:] Yes. 

[Surgeon:] Thomas has had a prolonged problem centering around obstruction in his lower air passages. 

You see that he's still on a ventilator, because if we let him breathe on his own he will very soon become exhausted and die.

[Emily:] He'd die?

[Surgeon:] Oh, yes. This is the kind of youngster that wouldn't survive 

without an intensive care unit and a whole intensive care philosophy. 

The equipment and the means just wouldn't be there.

[Interviewer:] And over here?

[Surgeon:] He has a major heart problem. 

It's a tiny baby. Not normal yet in his breathing.

The little one was born with a major narrowing of his nasal passages. 

He still needs to be watched carefully.

[Interviewer:] He looks as if he's fighting it.

[Anesthesiologist:] Yeah, patients who have respiratory disease do struggle. 

Our research is to help us first decide when a person is working too hard and when we must take over.

[Emily:] By hand? [Anesthesiologist:] Just by feel. 

The educated hand. When you have a patient's life at your fingertips, very hard on you emotionally.

[Nurse:] I think he'll be okay.

[Anesthesiologist:] And we know now that tragically many patients are dying because they do not get the benefit of care 

for lung disease which is reversible. 

And I think we have curable disease that is not really being treated.

[Interviewer:] And that's costly.

[Emily:] What's going to keep research going?

[Anesthesiologist:] If we had more money we could expand our resources.

[Doctor:] It may seem crass when we're speaking of human life to talk about money, 

but we have to face the fact that money is human life in a hospital. 

If we had more money we could save more lives.

[Interviewer:] Where do we stand on government support for research?

[Doctor 2:] Well, medical research is a very expensive proposition, 

and just the instruments and the manpower that are involved is something that no one institution could possibly afford.

[Interviewer:] But in the National Institutes of Health?

[Doctor 2:] The National Institute of General Medical Sciences was created to take care of general problems, 

such as anesthesiology, that are important to many different diseases.

[Anesthesiologist:] It acts as the patient does.

[Doctor 3:] Putting the funds into this sort of thing in order to improve patient care, the patient is the taxpayer. 

Is that a little better, yeah? I hope so. I hope so.

[Interviewer:] So you've never gotten bored?

[Doctor 4:] No, not in this kind of work.

[Interviewer:] How did you get caught up in it?

[Doctor 4:] I come from a background that these days I suppose would be classified as underprivileged, 

and was very fortunate indeed to be able to go to college at all in the depths of the Great Depression.

[Doctor 3:] Is that better? Is that a little better?

[Doctor 4:] At that time a whole new world of knowledge and culture opened that I never even knew existed. 

I thought in those days that I would stay in the humanities and probably become a professional philosopher. 

As I look back on it, it was an exciting and wonderful idea.

[Interviewer:] Was leaving philosophy a mistake?

[Doctor 4:] If you think of the humanities as being in place of hard science. 

People are complicated, they require and need somebody who really knows the scientific facts. 

Also knows what he doesn't know and brings compassion along with it.

[ Baby crying ]

[Doctor 4:] He's scared.

[Anesthesiologist 2:] They learn anxiety, even though they don't relate pain to anxiety. 

You've heard the phrase, "Scared to death," this has a good deal of scientific validity.

[Doctor:] Well, certainly when you go to the bedside of a sick man or an injured man you find tremendous anxiety. 

I don't know which is worse, whether pain is worse than nausea or nausea's worse than pain. 

Each one as it exists, when it exists is dominating.

[Interviewer:] You can measure it.

[Doctor:] One can put numbers in front of subjective items, yes. 

That's what we've been doing with pain for years, 

and also with nausea and drowsiness, we've studied some 20 subjective responses.

[Anesthesiologist:] Had we not made these observations on patients who were receiving drugs, 

we certainly would never have come up with that concept.

[Emily:] My friends think of anesthesiology as just a painkiller and a put-to-sleeper.

[Anesthesiologist:] It's no longer just take away pain, it's what is pain?

[Interviewer:] You mean we don't know?

[Anesthesiologist:] Well, you saw, of course, the four micro-pipettes which permit the intercellular recording 

and also the application of very very minute amounts of drugs to study the mechanism of pain, reaction of cells.

[Interviewer:] What else?

[Anesthesiologist:] The other area that we're looking into are sociologic and psychologic aspects of pain. 

Trying to decide, what are the factors? 

Our pain clinic is really a multidisciplinary facility, whose goal is to provide the environment 

to this team of physicians to work in parallel, rather than, the patient goes to this fellow and to this fellow 

and this fellow and this fellow and the only common bond is the patient.

[Doctor:] What do you feel here? [Patient:] Numbness.

[Doctor:] Tell me when it's getting sharp again?

[Patient:] Now.

[Doctor:] Do you have to take pain pills?

[Patient:] I was taking 15 to 17 a day, I think. 

I figured out roughly I've taken between 2500 and 3000 in six months.

[Surgeon:] No, I don't know the answer to handling chronic pain. 

These people might think I've done successful surgery but they continue to have back pain. 

I'm sure it comes from a variety of causes.

[Doctor 2:] There does seem to be some relationship between the way that she shows her pain, 

gritting her teeth, but letting you know she really hurts anyway.

[Doctor 3:] She speaks with love and devotion and gratitude to this process. 

She commented too that if it weren't for the back pain and things were now comfortable enough 

so that they could be having an enjoyable time together.

[Surgeon:] She is a 53 year old housewife who came to us about a year ago complaining of low back pain.

[Doctor 4:] Is the pain there all the time?

[Patient:] No, it isn't.

[Doctor 4:] How about moving to the side?

Is that bothersome?

[Doctor 4:] Anything else make the pain worse?

[Patient:] Well, I don't give into it at all, because I have to keep the home going.

[Doctor 5:] Aren't you involved in getting into a new house?

[Patient:] Yes, I have found a new place to buy, what I wanted and supervised all the moving and everything, so.

[Doctor 5:] You were doing all of the moving?

[Patient:] I supervised all of it myself. 

Bought the house, sold the other one, did all the managing myself. 

My husband continued to work every day.

[Doctor 5:] So, he didn't have to take any time off?

[Patient:] No, he didn't have to take any time at all off of work.

[Doctor 5:] It's been my understanding that this is kind of the way you do things, is that you take much of the responsibility.

[Patient:] I like responsibility, I always did. So, it works real well.

[Doctor 5:] This has been the case for most of your life.

[Patient:] All my life it's been the case, right.

[Doctor 5:] People look to you to...

[Patient:] Rely on. I started working at seven, when I was seven years old.

[Doctor 5:] What did you do then?

[Patient:] I picked cotton.

[Doctor 5:] Is that so?

[Patient:] That's right, I picked cotton. 

Saved my money and bought myself a pair of red goose shoes. Just beautiful.

[Doctor 5:] Was that your first pair of new shoes?

[Patient:] Well, no, it was my first pair of red goose shoes.

[Doctor 5:] Red goose shoes, I see. I see.

[Patient:] So, I've worked, kept a four-bedroom home, did all the gardening, all the yardwork, 

and worked 40 hours a week until I hurt my back.

[Doctor 5:] And how did that change things?

[Patient:] And all, everything completely changed.

[Doctor:] I think anyone who says, "I hurt, I'm in pain," I think that it is an emotional experience, 

total experience.

[Anesthesiologist:] This is clearly one of the major problems of our age. 

Levels of perceptions of just about everything. 

Things that are very hard to define, but they are all related to consciousness in some way. 

Presumably if one could halt the degradation of the body, which is going on every instant 

and to suspend it totally and then reactivate it again on another planet, 

then we could afford to spend literally years, in terms of space travel.

[Emily:] I suppose the anesthesiologist will be the specialist in long space travel, maintaining us delicately through time.

[Interviewer:] Back to Earth.

[Director:] There must be a certain amount of what I call productive leisure, for contemplation and study.

[Interviewer:] As director of the National Institute of, uh, 

[Director:] General Medical Sciences.

[Interviewer:] How do you buy brains?

[Director:] I've never been able to buy brains and I'm not sure anyone else does really. 

You can buy a certain high-grade skill, but you don't buy brains, I'm convinced.

[Interviewer:] What brings a good man into the field?

[Director:] The excitement of being able to develop new information and new knowledge. 

And it's particular gripping when clinical research is involved, to anticipate where trends are going to develop. 

It's very much as if one is riding a surfboard just within the fast-moving curl of the wave. 

The crowning point of the whole series of experiments, perhaps involving years of time.

[Technical Advisor Edgar Lee, Jr., M.D.]

[Project Supervisor-Helen Neal, Directed by Tracy Ward and edited with Anita Posner, Molly Smollett] 

[Producers Louis Mucciolo, Thomas A. Pyle] 

[Grateful acknowledgement for Leonard Bachman, M.D., Henry K. Beecher, M.D., Henrik Bandixen, M.D., John J. Bonica, M.D.] 

[Robert D. Dripps, M.D., Richard Kitz, M.D., Myron Laver, M.D., Emanuel E. Papper, M.D., Hanning Pentoppiden, M.D.]

[Theodore C. Smith, M.D., Harry Wellman, M.D., and Dr. Frederick L. Stone, Director National Institute of General Medical Science] 

[Cooperating Departments of Anesthesiology: Hospital of The University of Pennsylvania, Massachusetts General Hospital,

Columbia-Presbyterian Medical Center, The Children's Hospital of Philadelphia, University of Washington Hospital] 

[Produced by Audio Productions a Division of Novo for] 

[The National Institute of General Medical Sciences, National Institutes of Health, U.S. Department of Health, Education and Welfare]

[Sound of waves crashing on the beach]