Foreword by the late Dr. Y. G. Bhojraj

Dr. B. S. Gharpure (F.F.A.R.C.S.) is one of the senior most anaesthesiologist of the city of Bombay and one of the few Indians who has got the highest qualification in Anaesthesiology, namely Fellowship of the Faculty of Anaesthesia Royal College of Surgeons, London by examination.
He retired as an Honorary Consultant and Professor of Anaesthesiology of the K.E.M. Hospital and G. S. Medical College, Mumbai. He was a recognized teacher of Bombay University and was examiner for D.A. and M.D. in many universities.
Very early in his practice, he realized that to conduct a safe anaesthesia in private nursing home in the city of Bombay was an entirely different proposition than to conduct cases in a well-equipped teaching hospital. He also realized that there was no consideration in the specialized postgraduate teaching, to equip the students, majority of who opted for the private practice. The full time teaching staff at the teaching institutions are not at all equipped to fill in this gap as most of them are not conversant with the varying degrees of compromises one has to work with in private nursing homes. The compromises mainly arise out of financial constraints and the universal apathy of the surgical colleagues, who own and run the nursing homes.
Dr. Gharpure has tried to give the benefit of his experience to the practising anaesthetists who have to conduct their work in small private nursing homes not only in Bombay, but also in the mofussil area. I am sure the book will secure this purpose, and the practising anaesthetists will find the book quite useful.
I, personally, may not agree with the degree of compromise one should accept as an anaesthetist in conducting the anaesthetic management of his cases but that is not the relevant issue here.
I am sure that the practising anaesthetist will find some useful information and help him in administering safe anaesthesia in a severely compromised position of a private surgical nursing home.
Dr. Y. G. BHOJRAJ
Hon. Prof. of Anaesthesiology,
K.E.M. and Bombay Hospital.
M.B.B.S., D.A. (BOM.)
D.A.F.F.A.R.C.S. (LOND.)

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Acknowledgements

I sincerely acknowledge here some of the many people who helped me in my life and profession; each one a gem of a personality (listed alphabetically):

• The late Mr G.M. Abhyankar (affectionately known as Dada) and Mrs. Mangala-tai (late, affectionately known as Vahini) Abhyankar. They helped me as if we were relatives. After my return from UK , Dada helped me monetarily and in all aspects till I settled down. Dada-Vahini were always willing to help me both financially as well as in domestic matters. In the early days they provided me with phone facilities till I was allotted my own phone.
  
• Dr. G. D Adhia (late); who had immense faith in me.
  
• Dr A.N. Baliga (late) who showed immense faith in me even though I was not a student of the college. During a prolonged operation on a practicing doctor, he would turn around every hour and ask me if I was comfortable.
  
• Dr Y.G. Bhojraj (late)- My teacher, my guide, and advisor throughout my career.
  
• Dr. S.D. Bapat Urologist surgeon my colleague from KEM since 1975 till date. We contine and will continue hence forth. Very sincere to his patients, gives very frank advice based on humanitarian grounds and always a successful surgeon. After so many years we still maintain good working and family relations.
  
• Dr. A. J. Dhruva (late)- Retired as a professor and Head of Department at KEM. He saw to it that there was no tussle between me and him. He issued orders per the Dean’s instructions but gave me the laxity to obey them. I had already indicated to him that I will be working with resignation letter in my pocket till my “super annuation.”.
  
• Dr Gadre (late E.N.T. surgeon) and Mrs. Gadre; they both supported me and showed immense faith in me during their career and mine.
  
• Dr. Pradeep Joshi - A colleague Anesthetist. He considers me to be his guru afte I anesthetized his cousin at Dr. Bapat's place. We had a hearty talk after surgery. He was convinced of my technique which he considers that no teacher of his at J.J. hosp. taught him. He without fail rings me up on "Guru Purnima day" with respect.
  
• Dr. Karmarkar. During the absence of my teachers who were his regular anesthestist, he relied upon me for all major cases. Even after return of my teachers he continued to support me in my practice.
  
• Mr. N.S. Pathare (late); he was more than a friend. He helped me in all respects. In the initial stages with A/Cs filing of income tax returns, dailiy difficulties till the unexpected early end of his life.
  
• Mr. Patel- The orthopedic theater in charge during my work in the Orthopedic department.
  
• Dr. Talwalkar (late, senior); he supported me in the beginning of my practice but discontinued due to some misunderstanding of my remarks about aseptic procedures. But his son again supported me and after a lapse of 3 months we started again and all my suggestions were honored; even non-anesthetic suggestions. After a lapse of about 40 years we parted company as he sold his nursing home and moved to a place where my daily commute would have been about 2 hours to and fro in the evening. He is still in contact for medical, surgical, anesthetic, or any matter.
  
• All the surgeons whom I worked with and Hon. Professors at the K.E.M. hospital, Mumbai.

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Why this blog?

I have felt that the training in theory and practice in Anaesthesiology in teaching hospitals for a period of three years or till a degree in M.D., is not enough for practice outside a teaching hospital. The student anaesthesiologist is never exposed to a new environment nor are the teachers capable of guiding these students in real-life situations. For the teachers the rule of the thumb is safest and has got to be followed. If one imagines a spectrum beginning with white and ending in black, the training in teaching hospitals prepares you for the white or grey.
This spectrum encompasses all patients one faces in private practice. The white representing the totally fit patient and as we proceed towards the darker end of the spectrum the patient with complications, some of whom can be helped and those whom cannot. The population that lies in the totally dark end of the spectrum, are patients totally unfit but yet must receive anaesthesia in order to save their life. A patient who needs surgery can never be refused anaesthesia. There are times where the anaesthesiologist has to use his total experience skill and training against all odds where routine equipment may not be available. One can say he has to use the “Computer” that God has provided rather than depend on monitors, which may not be available.
What is given in the books forms the baseline and how much one has to compromise depends on the person’s training and experience. The narrow vision provided by theory for safety has to be widened in practice with total knowledge of theory. Hence one feels that after a long innings in Private Practice of Anaesthesia one has to record one’s experiences for the sake of posterity. In a very difficult situation the pearls of wisdom may be far more useful than the tons of books which only provide just guidelines.
The following pages record my experience, which may guide a trained person when all fails. Some Pundits can criticize the views and give a long armchair lecture suggesting how best and safely, with the modern monitoring gadgets, one can overcome the situation. However what the lecture will mean in short is “refuse anaesthesia if the equipment and facilities are not available”.
One can talk of jet age and progress that science has made and work accordingly. But also one cannot forget the uneven economic growth from villages to metropolis. It will be foolish to say that a particular drug or equipment is outdated in world literature and hence needs to be condemned. One cannot ask a villager to buy car, tractors and water pumps and discard the bullock cart and the equipment he is using. There is a wide gap between the teaching hospitals, sophisticated metro hospitals and primary health centres. The availability of funds, supply of essential day-to-day requirements is very poor. It is in this situation that guidance is necessary and not criticism.
This blog is meant to be useful for the trained anaesthetists working in mofussil or in small nursing homes where the whole situation is different. After training in Anaesthesiology for three post graduate years these few pages are meant to enlighten the anaesthesiologist on situations faced in practice and measures to overcome them. A few cases are quoted as guides in safe conduction of anaesthesia.
I am guided and encouraged by my teachers and some very senior surgeons and well-wishers. My experience in Anaesthesia as medical student, then a qualified doctor and lastly my work dating back from 1952 to date have helped me to compile this information. This information should not be quoted as evidence in court of law but guide one in difficult situation. My training in England taught me that all patients who deserve surgery even in life saving situations equally deserve fitting anaesthetist help. One’s own conscience is the guiding principle and everything is done in the best interest of the patient.
The recent medico-legal advancement sometimes puts limit to the help one can render in trying situations. However after consulting the surgeon and talking to the relatives of the patient himself one can sort out the problems. Taking “Death on Table” consent does not solve the problems.
I do not blame the teachers in teaching hospitals. They are doing an excellent job in the college and hospitals. They are expected to train the theory and practice in an ideal situation where all modern gadgetry is available, assistance available in plenty, the drugs and alternatives are available at all times and in the absence of any one of these, they have the “right” to refuse anaesthesia. They have no knowledge of the situation in private practice and anaesthesia in mofussil. They have no idea that the surgeon has the latest Boyle’s Apparatus but no gases, which are delivered by train or truck once in fifteen days. For them absence of N2O prevents them from proceeding with induction. They have no idea whatsoever what situation exists outside the teaching hospital. And hence I consider them to be bad teachers. They show only one side of the coin to their students and they fail miserably as to what the other side works like. No arguments and advice is given to juniors who are likely to venture in private practice or work in mofussil. They can be compared to a Tonga driver who drives the horse with blinkers. The horse has to look straight and obey the command. The students are totally brain washed. “No arguments do as I tell you” commands.
The anaesthetist coming out of teaching hospitals have no idea whatsoever what lies ahead. Their teachers are not competent to guide them. At least they can frankly tell about their merits in hospital practice but it forms only the basic fundamentals. They must be guided and advised to work with any experienced anaesthetist in private practice or working in mofussil. Here again just a very senior anaesthetist may not be a good choice, as he will be working in Five Star hospitals and nursing home. My teacher when approached used to frankly tell these young anaesthetists that he is not capable to guide them. He used to suggest some successful anaesthetist in private practice.
The teachers in teaching hospitals are totally book oriented. According to them ether and trichloroethylene are totally outdated open drop ether anaesthesia is a hypoxic anaesthesia and air as carrier gas has no place in modern practice. For them even Thiopentone and Scoline are outdated and dangerous as the books and journals are quoting.
Their techniques are totally gadget oriented and even if one gadget is missing they have sufficient ground to refuse anaesthesia. I do not say that these modern gadgets are useless. Nowadays they assist in safe conduction of anaesthesia in any situation. Pulse oximeter has become the essential gadget but clinical acumen can definitely guide you in the absence of such gadgets.
During the end of my residency my teacher advised me to do something different than routine every time. Replace spinal with G.A., give high spinal, and eliminate one drug everyday. This was a little bit difficult, as we did not have many drugs to replace. Yet I kept it on. I eliminated Thiopentone, Scoline, Tubarine, Flaxedil etc. It is really a good exercise and I will advise all to practice before venturing into private practice.
I am thankful to some of the surgeons with whom I am associated for the last 30 years or more. They always insisted that I must write my experiences. To mention the names of the surgeons will not be out of place, as the blog exists to day because of their encouragement. Dr. S. D. Bapat, Urologist; Dr. V.N. Shrikhande, Gastro-intestinal and general surgeon; Dr. T.N. Ursekar, Ophthalmologist and Vitreo-Retinal surgeon, and Dr. C.A. Talwalkar, Orthopaedic Surgeon.
I think the information herein will be of immense help to surgeons. To know something about the patient's head end is a must for each surgeon for the success of his surgery and the ultimate recovery of the patient. I recommend the book for surgeons too.

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The inspiration for this blog

This blog provides some basic textbook-like knowledge based on every day experience. It is hoped that the content will enlighten the reader in basic teaching and furnish basis for well-provided hospital work. Currently, there is no book available which guides a qualified anaesthesiologist working in smaller nursing homes and in district and mofussil hospitals. All the practical difficulties and ways to remedy them or meet them are tackled in the current text.
After my return from the United Kingdom while on the threshold of leaving a full-time job, I was faced with the mountainous task for collecting equipment for private practice in smaller nursing homes. At this juncture I had an opportunity to meet Mr. M. R. Rao and his father. Both of them were friendly, knowledgeable, and gave me well-directed advice as also provided me with all basic equipment needed to start on my own. I am proud to state that I am still using the first bellows unit manufactured by him. Mr. M. R. Rao was truly a friend for a practising Anaesthesiologist starting on his own. Knowing the financial encumbrances that a novice faces he never insisted on advance payment for equipment. This was not solely my own experience but also of others whom I directed to his establishment “Anaesthetics”.
Always keen on being in step with the advances in Anesthesiology, Mr. Rao was very obliging about satisfying all his patrons with any kind of technological information or equipment that was needed. Shopping for new gadgets in Anaesthetics was my favourite hobby, which made me frequent Anaesthetics. He too was very good at reciprocating my interests. I could count on a telephone call from him as soon as any rare item arrived at the Anaesthetics. During my practice I felt the growing necessity of a ventilator. I remember pestering him to manufacture one. Ultimately he did succeed in manufacturing an indigenous ventilator and was open to any criticism. This was true of any apparatus or gadget that was manufactured by his establishment. Any constructive suggestions or modifications suggested to him were promptly implemented. I do not recall any single person who was unhappy with Mr. Rao of Anaesthetics. Over the years Anaesthetics has grown tremendously yet the basic principle of providing helping hand to private practising anaesthetists remains the guiding principle. The various products manufactured are helpful to the anaesthetists. “Anaesthetics” also provide the day-to-day anaesthetic drugs. This noble and helpful friend suddenly left this world without any illness or any warning of any serious illness.
His brother, Mr. Mundkur, is now carrying forward the good work done with the same zeal.
I am also indebted to some senior surgeons with small nursing homes who encouraged me to write my experiences. The surgeons definitely found the difference between the anaesthetist in private practice and those in teaching hospitals. The adaptability and compromise was totally missing in teaching hospital. The similar situation was easily tackled by anaesthesiologist in private practice without any compromise towards the safety of the patient.
Last but not in the least, this book has taken shape due to my wife’s encouragement to jot down all the interesting cases and how I surmounted them. She persuaded me to write a book. Writing another text book did not appeal to me. But in later years I did find the necessity of writing for posterity. There are plenty of textbooks on the shelves of teaching hospital libraries but practical hints are never elaborated in textbooks.

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Private Practice- Learning the ropes

After leaving the shelter of a teaching hospital you must spare a minimum of two to three weeks as the “learning road period”. An anesthesiologist fresh out of a teaching hospital must observe one or more anesthesiologists already in private practice. This is important since the challenges in private practice are different in many respects than in a teaching hospital. The situation and set up changes from nursing home to nursing home. During this period do not try to assist the anaesthesiologist not even preparing the drug or handing over the syringes. Just observe what he does single-handed without any help from senior, junior or even a ward boy. Observe everything and after the case you may ask explanations for each of the procedures undertaken. Do not assist the anesthesiologist unless expressly called upon to do so.
Over these two to three weeks, you may realize, as I did, that:

• You are all alone and the only expert.
  
• Your equipment is handled by you alone and no one can help you.
  
• Help may not be forthcoming as each one is busy with his own job.
  
• You may be called upon to give a helping hand as necessary.
  
• The time to understand the situation and find the solution is very short. Judge the gravity of the situation quickly and make alterations to techniques or medications quickly.
  
• Pre-operative examination and evaluation may not be possible.
  
• Pre-medication schedule may not work due to many variables.
  
• In the beginning one can expect help from a senior surgeon.
  
• Cases are better worked up by the senior surgeon; a junior surgeon may not realize the gravity of the situation.
  
• Do not depend on the nursing staff in the post-operative period in small nursing homes.
  
• Judge the gravity of the situation quickly and make alterations to techniques or medications quickly.
  
• Balancing appointments and work schedule is always a challenge.
  

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Paperwork and Colleagues

Before I had chosen to specialize in Anaesthesiology I was a general duty doctor on emergency in a hospital where the work load was not much.A patient canme in to the hospital compound; she looked ill. I got her admitted, started an IV infusion and wrote down my notes. At 8:00 pm I handed over to the senior resident and went home. Before I left I told him about the emergency admission. I told him to have a look at the patient and le me know whether he is likely to need me. He said that he had looked at the patient and would not need me. Next day at 9:00 am when I arrived for my usual duty I was summoned by the chief and asked whether I had admitted an emergency. I said I did and I also told him that I had written complete notes and requested the senior resident doctor to examine the patient and le me know if I needed to stay. His voice changed and he was suspicious about my treatment of the patient. He asked me why I changed my diagnosis which was a query. I had not altered my diagnosis. The chief showed me the case paper. The scratched mark was in different ink. The entire responsibility shifted to the senior doctor who did not write his notes nor did he follow up on the case in the ward. Later, I was congratulated on my diagnosis; however, the patient was lost.

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Cautionary Hints and Tips

Endotracheal tube related cautionary hints and tips...

• After intubation turn the face of the patient on the side which is kept on arm board, based on the surgeon’s preference, with right arm out. The problem does not exist except for over extension of arm beyond 90º. Prevent it by putting the IV stand on the head end side of the arm board. Hyper abduction, arm below the table level and head rotated on the opposite side can lead to bronchial palsy. In my observation, maximum number of accidents occur with head rotated on left side (right mastoid)
  • due to linking of the ET over the airway or the bite block and
  • excessive oozing during surgery.
  
  
• In oedentous (patients with beard) patients and infants do not depend on sticking tapes to the ET. Always use a tape or bandage to tie the tube round the face. Stitching tapes easily give way and come out due to salivation, making it easy for the ET to come out.
  
• On operation on neck where extension is needed with a bolster under the shoulder, tape the eyelids with small tapes to prevent the eyelids coming apart due to gravity and draping, which pulls the upper eyelid down towards the table causing exposure keratitis and corneal ulceration. Fix the tube only after final position is given with bolster under the shoulder. If fixed earlier to the angle of the mouth, the tube can come out of trachea .
  
• In ophthalmic procedures, to prevent the sterile drapes from becoming wet, surgeons put a waterproof sheeting on top. In patients who are not intubated and the airway is not in place, patients find it difficult to breathe. Fresh air cannot enter under the waterproof plastic sheet and the patient becomes restless. Carbon dioxide accumulates under the drape and they start hyperventilating. This can be prevented by putting a 1 meter (approx.) corrugated hose under the drapes, which is communicating with the theater air. Ventimask is a must.
  
• Always fix the ET in patients with hyperextension of the neck after the position is given and it is confirmed that the ET is in the trachea and not abutting at the commissure or has come out.
  
• Keep a watch on the arm kept by the side of the patient is well tucked in with a tape keeping the arm close to the body. A loose arm and the surgeon or assistant leaning against the table can press the ulnar nerve against the edge of the table.
  
• Extravasation of 5% Thiopentone or other irritating drugs can cause median nerve palsy. Use 2.5% solution and inject under vision. Inj. Diazepam outside the vein can cause sloughing and ulceration. In the event of extravasation, inject normal saline at the site to dilute the extravasated drug and its effect.
  
• Confirm that the injection to be given is in the vein and not an abnormal artery.
  
• For a patient in prone position check and make sure that the abdomen is free from the operation table and is well supported on bolsters. Make sure that the face and head are in a comfortable position and well supported and that the ET is not kinking and is well fixed with a tape or bandage to the head. Manual IPPR should be continued till the final prone position is given. If connected to a ventilator, check it manually for good ventilation and then switch on the ventilator.
  
• For a patient in a sitting position, involve the neurosurgeon in fixing the head. After fixing check the ET, and tie the ET to the head support to prevent it from slipping with movements of head during surgery.
  
• After cannulating a vein do not forget to remove the tourniquet. A case is recorded where the anesthesiologist forgot to remove the tourniquet and went on injecting more and more of 5% Thiopentone to meet the requirement for surgery. The tourniquet was detected when the patient was shifted to the ward. In the evening when the surgeon visited the patient it was found that arm, forearm and palm had turned black, pulse good volume and all muscle movements normal. After slight exfoliation of epidermis the extremity was normal. The cause– diffusion of Thiopentone into the tissues with intact tourniquet; fortunately it was a venous tourniquet.
  
• In all patients operated under tourniquet, make a note of the tourniquet time and see that it is removed at the end of surgery. Check again when the patient is being moved to the ward.

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Private Practice Anesthesia- Do’s and Dont’s

The following offer some guidelines on private practice based on my experience:

#1-5: Private Practice Anesthesia-Do’s and Dont’s
#6-10: Private Practice Anesthesia-Do’s and Dont’s
#11-15: Private Practice Anesthesia- Do’s and Dont’s
#16-20: Private Practice Anesthesia- Do’s and Dont’s
#21-25: Private Practice Anesthesia- Do’s and Dont’s
#26-30: Private Practice Anesthesia- Do’s and Dont’s
#31-35: Private Practice Anesthesia- Do’s and Dont’s
#36-40: Private Practice Anesthesia- Do’s and Dont’s

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