In search of the ‘good anaesthetic’ for hip fracture repair : Difference, uncertainty and ideology in an age of evidence-based medicine

Shelton, Cliff and Goodwin, Dawn and Mort, Maggie and Smith, Andrew (2019) In search of the ‘good anaesthetic’ for hip fracture repair : Difference, uncertainty and ideology in an age of evidence-based medicine. PhD thesis, Lancaster University.

Text (2019SheltonPhD)
2019SheltonPhD.pdf - Published Version
Available under License Creative Commons Attribution-NonCommercial-NoDerivs.
Download (18MB)

Abstract

Hip fracture is a common life-threatening injury amongst frail elderly people and early surgical fixation under anaesthesia is advocated. It has long been suspected that mode of anaesthesia (general anaesthesia, induced unconsciousness; regional anaesthesia, interruption of sensation using local anaesthetic) influences outcome, however ‘conventional’ studies have consistently failed to demonstrate if this is the case. A similar proportion of patients receive regional and general anaesthesia; apparently decided more by institutional culture rather than clinical requirements. This variation is perceived by many as a scandal, and efforts are underway to ‘standardise’ anaesthesia. Standardisation is controversial however; anaesthetists seemingly cannot agree on what a ‘good anaesthetic’ actually is. In this ethnography I work with anaesthesia’s ‘scandalous’ variation in three contrasting hospitals. I ask how patients, anaesthetists and others understand, experience and enact the good anaesthetic. By adopting this approach, I have radically reconceptualised how hip fracture anaesthesia is described, what it consists of, and what is important about it. Blending a science and technology studies approach with my own perspective as a practicing anaesthetist, and drawing on sociological theory about boundaries, uncertainty and standardisation, I propose that a ‘good anaesthetic’ is not regional or general. These classifications fail to recognise the nuance and complexity that define ‘good’. I contend that, to patients, anaesthetists and their colleagues, a good anaesthetic: gets done today, withstands uncertainty, treads lightly and is easily forgotten. Hip fracture anaesthesia is not as it first appears. Though evidence-based medicine makes divisions along ‘obvious’ lines, it fails to consider the goals and ideologies that underpin practice. In this thesis I explain why we must reconsider how hip fracture anaesthesia is understood. By asking ‘how, why and when?’ rather than simply ‘what?’, I offer a vital and different approach to evidence and practice for researchers, clinicians and patients.