Regional anaesthesia — before or after general anaesthesia?

My good friend, Barrie Fischer, and I have debated this important issue on a number of occasions so I read his editorial (Anaesthesia 1998; 53: 727–9) with interest, but not without some concern. I am pleased that he concludes by recognising that the onus for proving the safety of major block performance in unconscious patients is on the proponents of the approach, but a little disappointed that he should refer to those who take the opposite view under the somewhat pejorative heading of ‘medical experts’. We, just like him, are anaesthetists. I also have two major questions. First, I ask why the block should not be performed first? An attempt was made to answer this, but I am not impressed. In my career I have worked in three hospitals where regional anaesthesia has been used extensively (Edinburgh Royal Infirmary, Boston's Brigham & Women's Hospital, and now Ninewells in Dundee) and the standard practice in each has been to perform the block first. If this is done carefully and gently I can see no need for an approach that, as noted above, he accepts has to be justified. The second, and perhaps even more important, question is to ask who looks after the general anaesthetic while the block is being performed? This is not even addressed in the editorial.