You are all alone and the only expert

During the training period in a teaching hospital expect to get help from senior, junior colleagues and even the theatre staff. Expect no help in private practice. Keep things ready and in order. In case one is going to expect difficulty, be frank and ask for help in advance from the surgeon. He will appreciate your candor and help you. He will never underestimate your capabilities. Life threatening situations must be discussed before hand.
Patients who are not seen and examined before need special consideration. Ask the surgeon if there is anything special about the case like diabetes, hypertension, previous myocardial infarction, drug allergies, and food intake. While preparing for the case do have a friendly chat with the patient. It may not have any relevance but that reassures the patient. Always browse through the notes to find any relevant history or biochemical findings. No harm asking the patient about the history of previous operations if any, dentures, and any medication patient is on. Some time you may get a curt answer that everything is mentioned in notes and laboratory reports. In such patients do not forget to tie a BP cuff and show that you checked. Reassure the patient that he will be awake at the end of surgery and that you are going to talk to him and then only shift him from the operation table. Ask whether he is accompanied by a relative or friend. Do not proceed if the patient is all alone.
In spite of these precautions you can come across surprises. I quote some cases.
A qualified (MS) surgeon did not find it necessary to mention that the patient was a case of Mitral valve replacement as the case was done under local and sedation. It was only noticed when the pulse was felt after the surgery started. It was irregularly irregular.
In another case the surgeon did not find it necessary to mention Coronary Bypass surgery as the patient was in only for Cataract with IOL.
The third patient was for radius ulna nailing, to my surprise after a scoline injection, he was found to have his jaw fixed with intra dental wiring.
In case of surgery on either side check from notes and the patient the site of operation. It had happened once that the surgeon had mentioned left side cataract. The surgeon had convinced the patient that only left side would be done. When the sister asked the patient, he told her that the operation was for the right eye. Sister without checking surgeon’s notes prepared right side. When I discovered the discrepancy, I asked the surgeon to check everything before he washes up. The operation had to be postponed as the pupil was not dilated on the left side and lens was kept ready for left eye.
Always check the patient with the notes. On one ccassion, a patient last on the list at 8.30 p.m. was brought on table by the house officer as a case of bilateral Gynaecomastia. After induction when the patient was being prepared, I brought to the notice of the operating surgeon that there is no breast enlargement. On detailed investigations it was found that no member of the surgical team had examined the patient. His brother who was a medical student brought the patient. The primary complaint was that his friends in the gym teased him for enlarged breast.
While working in England I remember a case where, after confirming the side of operation (Hernia) in the induction room by every one, the patient was wheeled to the operation table after induction. The operating surgeon started draping the wrong side. When I brought to his notice that the patient was being draped on the wrong side. The surgeon immensely thanked me. In situations like this you ask the patient and confirm from the notes, as you are the last person who communicates before he becomes unconscious.
While conversing with the patient you may find that he is from the same place of origin as you or you may be reminded of some person from the same place or same surname. Engage the patient in conversation; the patient feels that there is a friend in the operating room where he is lying tense and scared. Never estimate the age or assume relationship with the relations outside, it may sometimes embarrass you. A young man for vaso-epididymal anastamosis. The operation was nearly getting over. I went out to take a telephone call. One elderly looking female approached me to ask whether the patient is alright and how far the operation has proceeded. I was about to address her as the mother of the patient. However I asked her relation to the patient. To my surprise it turned out that the patient was her husband
While taking blood pressure you can observe the following:

• Breathing: rate, depth, abdominal or thoraco abdominal cough
  
• Patient with short neck, obesity, oedentous gums, and shaky teeth
  
• Examine veins on his forearms and palpate the vein, which you are thinking of cannulating. Doing so may avoid intra-arterial injection and the catastrophe following it.
  
• Patient with whole or partial dentures and whether they can be removed. If dentures are removable then ask him to remove the dentures. Dentures are difficult to remove after introducing the laryngoscope blade.
  
• You may ask him whether he has arrived on the operation table with completely empty stomach. Double confirmation is very important with illiterate patient.
  General condition of the patient. Emaciated, toxic patient, hyperthyroid patient, patient with pyrexia, severe anaemia, and previous operation scars.
  
• Whether the patient has passed urine before coming to operation table or is he catheterized. In female patients with all abdominal operations whether the patient is already having an in dwelling catheter.
  
• Any abnormal finding that surgeon or clinical notes do not mention like dilated veins on the left side of the chest wall, varicose veins, lumps and swellings or lymph glands. If anything looking serious, bring to the notice of the surgeon.
  
• Lastly the pulse indicating hypertension or hypo tension, irregularity etc.

All these observations are made while chatting with the patient and without indicating your worries. Discuss your concerns with the surgeon in his consulting room and not in the presence of the patient. Patients may have preferences about the type of anaesthesia, which they may have conveyed to the surgeon. Examples of these include but may not be limited to fear of general anaesthesia, postoperative vomiting, total reluctance of spinal anaesthesia or fear of post-spinal headache. So one has to be ready to change plan of action or change the technique altogether Similarly a glance at the patient as a whole can give much information, such as obesity, anaemia, oedema, orthopnoeic, restlessness, or jaundice. While taking the blood pressure one can inspect the veins, abnormal arteries, toxicity or anxiety. Simple questions like name, address, nature of work, age, side of operation, previous operations, nature and experience of surgery and anaesthesia can be helpful.
Do not treat patients with jewellery on the body, eye wear-contact lenses, and partial dentures. Have them hand their belongings to their relatives. This absolves you from liability arising from missing items.