Wednesday, April 16, 2008

MISERY ACQUAINTS A MAN WITH STRANGE BEDFELLOWS

by Malcolm Fisher (World Medicine October 1976)

Surgeons and anaesthetist have a curious sadomasochistic relationship. Roland and Oliver, Laurel and Hardy, Tristan and Isolde, Lillee and Thompson have been dissected, analysed and lauded. The equally temptuous relationship between surgeon and anaesthetist is less lauded, and sometimes less laudable.

The love-hate aspects of the relationship are governed by two historical truths: without surgeons, anaesthetists would be unemployed (hence the diversification into intensive care, pain clinics, hyperalimentation, and the like), and, because all surgical progress has been made possible by anaesthesia, without anaesthetists, most patients would rather keep their gallbladders, prepuces, and ugly noses.

As surgery has progressed and become more horrendous the function of the anaesthetist has changed from providing good operating conditions for the surgeon to saving the patient from the surgeon. As one cynic put it: "They will do brain transplant one day, just as soon as I can work out which bit to wake up".

I was a little taken aback but I soon learnt that these rules, like many other things he told me, were essential for survival. On my second day, he initiated me into the inner circle which knows the Cook's three laws of surgery:
1.Surgery begets surgery.
2.The adjustment of an operating light is an immediate signal for the surgeon to place his head at the focal point.
3.No substance is more opaque than a surgeon's head.

After three weeks I believed I had anaesthesia mastered, much so that I asked a surgeon what the difference was between a three week resident anaesthetic and a twenty year consultant anaesthetic.

"Very little," he informed me brutally. "the only major difference is that when something goes wrong and a junior is anaesthetising, I know, and when a consultant is anaesthetising I find out in the tea roomwhen it is all over."

I confronted the anaesthetic philosopher with this disturbing information and learnt the next most important lesson. "Never tell the surgeon anything. There is nothing he can do and he will only get in a flap."
There were only four things he said to tell surgeon in time of
crisis.
1."Please get the retractor off the heart."
2."Could you stop a few bleeders and give me time to catch up."
3."Could you give cardiac massage."
4."You can stop now – he's dead."

I then went on and learned the complexities of the surgeon-anaesthetist relationship. I heard of the famous Jones technique of anaesthesia where the anaesthetist stands at the foot of the table and tells the surgeon how to operate while the surgeon's assistant hold the patient on the table. I learned that fitness for anaesthesia was a meaningless term; anyone who could lie down was fit,
but fitness for surgery was a different matter entirely.

Fitness for surgery can be decided over the telephone by asking who the surgeon is, where the patient is going after, and what the operation is. All the pre-operative examination tells you is how and when.
I learned to understand the prima donna complexities of the surgeon and to recognise when the operation was not going well.
All surgeons follow the same procedure.
* Adjust retractors
* Reposition assistants
* Make bigger hole
* Change sides
* Order multiple light adjustments
* Ask for more relaxation
* Curse scrub nurse, resident, registrar, health commission, government, anaesthetist, and deity
* Remove alternative organ and close.

Over a few further years I learned the two other important things that every anaesthetist must know. Surgical textbooks always list causes of excessive bleeding during surgery. They include incompatible blood transfusion, massive transfusion, poor position, halothane, ether, patient too light, patient too deep, hypoxia, hypercarbia, straining, and so on. They never mention scalpels, tearing vessels or swabbing away clots !
In fact when a surgeon glares " Can you do anything about the bleeding?" the best reply is "Certainly, but who will mind the patient while I scrub?"
There is also a list of great surgical lies which every anaesthetist
will recognise.
* "Put him to sleep, I'll be down in five minutes."
* "He is old but he is fit."
* "You will like her, she's and old dear."
* "I haven't cross matched blood, we don't need any."
* "Don't put a tube down, it's just a quick snatch."
* "I'm just going to open, have a look, and close her."
* "She will die if I do nothing."
* "I'll be finished in ten minutes."
Surgeons appreciate a reciprocal number of anaesthetics lies as they appreciate the law that fitness for surgery is universally proportional to time of day.
And let surgeons beware when they hear:
* "The blood pressure is 123/72."
* "The patients is maximally relaxed and won't breathe for a week
if I give any more."
* "It's not cyanosis, it's just the bloody lighting."
* "Don't go away, it will be two minute turn around."

Friday, April 11, 2008

Liver Transplantation

In our center we have done about 12 Orthotopic Liver Transplantaions. I was fortunate to be a part of the Liver Transplantation team recently. I have tried to capture some of the important stages of the perioperative period
here

Blood conservation in cardiac surgery

In our day to day anesthetic practice, we are so busy saving lives, reviving arrests, that we spare little thought to improving our methods. Blood transfusion is one such intervention which needs to be looked at carefully. It can be harmful. It is more often than not unnecessary. This talk was given with a view to educate our fraternity that bloodless cardiac surgery is very much a possible thing, not just a pipe dream.

2nd National TOE workshop under the banner of IACTA, between 15th to 17th October 2008

The second national TEE workshop is being conducted at Narayana Hrudayalaya in October this year from 15th to 17th. Like the previous one it is going to be a hands on workshop. Registrations are limited to 25 only.Those who are interested may contact at the addresses given in the poster below.

Thursday, April 10, 2008

Allowable Blood Loss Calculator

Check out this ABL calculator.. I don't know how useful it is in our OR scenario, but I found this guy's effort to create something like this very interesting!

Workshop on Transoesophageal Echocardiography

Recently we conducted a IACTA( Indian Association of CardioThoracic Anesthesiologists) certified national level workshop on Transoesophageal Echocardiography. It was a first of its kind effort by Cardiac Anaesthesiologists in India. It was a three day workshop, with eminent faculty members from all over India and abroad. Since the idea was to give as much hands on exposure as possible to the delegates, the registrations were limited to thirty eight only which left many more who very keen to particpate,disappointed. The workshop included a lecture series on important and relevant topics in TEE, porcine heart dissection by each participant and total of three hours of hands on TEE training in the OR over two days. The workshop was not only well attended but also well appreciated.
I was privileged to be one of the faculty members in the workshop( and also one of the participants!). What you see below is my presentation.

Saturday, April 5, 2008

Grievance of a patient in ITU..

I happened to stumble upon this review on our hospital. Not very amusing at all.. Music in ITU! I only hope the reviewer has been satisfactorily replied to and all the necessary clarifications have been given.

About Narayana Hrudayalaya


Narayana Hrudayalaya is one of the biggest cardiac care centers in Asia with about 25 cardiac surgeries in its 12 fully equipped state-of-the-art cardiac ORs and close to 50 cardiac interventional procedures in its four cathterisation labs being performed every day. "Caring with compassion" being the motto of the hospital, it is striving hard to provide highly affordable and quality health care to the masses. The hospital has grown remarkably in the past few years and has been highly successful in achieving its goal. In an attempt to duplicate this success in other specialties of health care, Centres for Neural Sciences, Trauma care and Orthopaedics and Advanced Surgery including Liver and Kidney Transplants have been started under the aegis of NH. A 1000 bedded Cancer Hospital is also on the anvil. For more information about the hospital please visit our official web site here.