Taking appointments is a challenging task in private practice. No matter what you do, you cannot please everyone. You have to have a clear conscience and act accordingly. You must keep your first appointment of the day on time. After that it is left at the mercy of hundreds of situations beyond your control. There is no point in secreting adrenaline and it is better to inform or arrange one of your colleagues to manage. Whatever one does, one has to hear from the surgeon “you have taken appointments very closely”. They forget that the anaesthesiologist is being delayed by one of their own kith. I once seriously consulted my teacher about this issue regarding schedule and being on time. His advices was to attend your first case in or before time and in case of delay say “sorry” and start the case. An experienced anesthesiologist can narrate hundreds of stories regarding appointments where no explanation is valid and you are blamed. Forget it and remind the surgeon of the delays that he has caused you and keep your cool; make sure that your anger is not reflected in the conduction of your next case. The surgeon will always have some explanation or excuse. Always talk to the surgeon previous day. A hernia on list can be bilateral hernia or an incisional hernia. This can upset your timing schedule. In any case inform the next surgeon about your whereabouts and the cause for your delay.
In cases you have met with complications or death, discuss the case with your teacher or any senior anesthesiologist. Narrate as things have happened truly, you will always get proper explanation. In case you are not satisfied tell the senior frankly and seek the explanation from another senior anesthesiologist. The same problem can recur in your practice and hence it is better to remember the mistake you have committed.
Monday, May 11, 2009
Balancing appointments and work schedule is always a challenge
Wednesday, March 25, 2009
Techniques of Anesthesia-GA with Muscle Relaxant
GA with muscle relaxant
The basic principal is based on a triangle. One side represents perfect muscle relaxation, the second represents amnesia which is achieved with N2O or low concentration of any anaesthetic agent hyperventilation – Alkalosis depressing the awareness column of the Central Nervous System.
Ether 2% N2O or trichloroethylene 1 to 1.5% suffice (Halothane 0.5% muscle relaxant is administered as supplement where necessary Hyperventilation (alkalosis) potentiates both muscle relaxant action + amnesia. The muscle relaxant should be given as and when necessary and not at fixed timing depending on the pharmacological action. Do not use muscle relaxant for last 15 min. one should give small supplement of Thiopentone to achieve the goal. Reverse the muscle relaxant with atropine and prostigmine. It is mandatory. Even 0.25 or 0.5 mg of prostigmine makes an appreciable difference in patients who do not exhibit much relaxant effect.
Some points:
-Closed circuit, carbon dioxide absorber
-Never practice completely closed circuit
-The gas flow should not be less than 4 lit/min.
-Do not completely depend on the carbon-dioxide absorber
-Rising BP and tachycardia + lightness of anaesthesia should be taken as inefficient
-carbon dioxide absorption or elimination
Techniques of Anesthesia-Using Ether
Some important points with regards to using Ether:
Endotracheal Tube
My practical experience with endotracheal tubes...
Always maintain all sizes of endotracheal tubes for infants, small children and adult. Few adult cuffed endotracheal tubes are a must. Nasal soft tubes size 8, 9, 10 can be lifesavers. They should be sufficiently long. They can also be used for passing a Ryle’s tube in an unconscious patient. After threading the Ryle’s tube in a well-lubricated nasal tube is passed in Oesophagus and Ryle’s tube is threaded down into the oesophagus, the nasal tube is withdrawn. If it is difficult to pass the tube nasally, pass the tube orally push the threaded Ryle’s tube and withdraw the soft tube. The oral Ryle’s tube can be railroaded into the nose with the help of catheter fixed snugly in the end of Ryle’s tube. Push the Ryle’s tube, which is stiff. Do not pull the catheter.
In case of difficult intubation a soft portex tube is passed nasally which mostly enters the larynx. Sometimes it remains anterior to the epiglottis, which can be placed posterior to the epiglottis with Magill’s forceps and threaded to enter the larynx. Sometimes the tube gets hitched against the anterior commissure and cannot advance in the larynx and trachea. It can be manoeuvred by slightly flexing the neck, which corrects the angle between the advancing tube and the trachea.
All endotracheal tubes must be washed by you with soap and water and a jet of water forced down the tube to remove all the left over secretions and finally cleaned by brush and water and dried with a towel. This will save your embarrassment when a freshly boiled tube for use shows secretions of the previous case or a foreign body like a cotton swab or even a cockroach, even a nasal turbinate has been recovered.
Nasal endotracheal tube advanced before oral extubation in case of full stomach makes life easier. Sometimes solid food and big blood clots cannot be aspirated from the oropharynx when extubated and the patient struggle for breath. Nasal tube maintains the free airway and allows sufficient time for the patient to vomit out stomach contents if he is conscious and clear the oropharynx.
All tubes should be fitted with female Noseworthy’s connections. Cobb’s connection is only useful in cases with wet lungs when intermittent suction is mandatory. The connection must be tight fitting and of correct size. Do not try to fit bigger connection as it may tear the tube (rubber).
Cuffed ET should not be used all the time. It spares your cuffed tubes. With use of air it is hardly necessary if the bellows or respirator are used. As far as possible do not inflate the cuff. Pass the proper size tube. If the air leaks by the side of tube is more, replace the tube with the next size. Use of cuff can cause oedema and damage to the mucous membrane of the trachea in long duration cases. After placement of ET inflate the cuff yourself. Over zealous Assistants always tend to over inflate the cuff. The over inflated cuff becomes a very strong stimulus and in light plane of anaesthesia it can lead to intense bronchospasm endangering life if not detected. Cases are known where inflation becomes impossible due to bronchospasm and cyanosis start appearing in spite of oxygen rich mixture used to inflate the lungs thus produced by an inflated balloon. The bronchospasm produced by over inflated balloon does not respond to usual bronchodilator treatment like injection of drugs. It only responds to:
-Deflation of cuff
-Removing the ET
-Deepening the level of anaesthesia
The simplest in the situation is deflation of cuff. The remaining methods appear to be dangerous and are not productive. For conduction of cases always have 3 sizes ready. Also do not forget to keep a nasal tube of appropriate size always ready. It is specially important in cases who are overweight, short neck or where the mouth cannot open adequately. Nasal intubation can prove a life saving procedure in all difficult intubations. In a planned case always ascertain the freedom of breathing through each nostril separately. Lubricate the nasal tube thoroughly, do not use force at any stage. You can have two obstructions while passing a tube through the nose, one at the nasopharynx where it meets the Passavant’s ridge and secondly while the tube meets the larynx at its outlet. The first difficulty should be solved by putting a finger in the nasopharynx as you advance the tube to hook it and bring it out into the pharynx, and second difficulty can always be solved by flexing the neck so that the angle of the advancing tube corresponds with the trachea. The difficulty is due to the nasal tube hitching against the anterior commissure. Do not force the nasal tube. It can cause bleeding.
Rubber tubes last about a year or more and hence one should not hesitate to boil the tube for 2 minutes before each case. Discard the tube when the tube shows signs of perish. The boiled tubes before use must be cooled and in emergency cooled under tap water. A case of an adult female is recorded who had an intubation with hot tube. This patient for Thyroidectomy needed Tracheostomy in the postoperative period. This precaution is a must in case of children and infants.
Inspect the tube before giving it for boiling for any foreign body (Cockroach) or debris. Sometimes cotton swabs used for cleaning have been detected. So look down the tube after straightening to find the presence of any obstruction. Unimaginable objects have been accidentally found inside the tube. In small tubes and Oxford tubes run the water through the tube and pass a stillette to ensure perfect patency. One must possess all types of tubes like armoured, nasal, Oxford, infant and special for specific use. If one can obtain laryngeal mask airway all 3 sizes.
Endotracheal tube connectors
One should have sets of different connections like right angle, Cobb’s, and curved as in some situations one requires various angles and various other uses for the connector. A Cobb’s connection can be used when one has to resort to suction intermittently and for giving IPPR with thumb technique and for use as Ayre’s T piece if it is not available. For routine use it is better to have a plastic female nose worthy connection fitted to each tube and a male Noseworthy connection to the catheter mount or the various unidirectional valves can directly connected to Noseworthy connection with metal connectors check the catheter mount.
Tuesday, March 24, 2009
Judge the gravity of the situation quickly and make alterations to techniques or medications quickly
In spite of all instructions and information one is likely to come across patients whose records do not reflect the conditions suddenly detected on operating table. One has to be very cautious about these patients and one might have to change strategy suddenly.
-Patients orthopnoeic
-Patients having difficulty in breathing
-Inability to open jaw
-Tonsil
-Tooth septic with spreading infection
-Patient in CCF or LVF
-Patient in shock state
-Ectopic beats
-Duodenal perforation, bowel perforation, leaking anastomosis
-Abdominal catastrophe
-Oedema face or legs
-Patients very pale due to sudden massive haemorrhage like burst ectopic pregnancy.
All these and many others can change the plan and new strategy will have to be adopted. All the pros and cons must be rapidly thought and may well delay the procedure, than putting ones foot into it.
In a really difficult situation where the decision is likely to end in fatality one should not hesitate to take a second opinion from a senior anaesthetist. There is no need to have feeling of inferiority and shame while seeking the help of a senior.
Do not depend on the nursing staff in the postoperative period
In above all situations it is the duty of anaesthetist to leave full instructions or leave the nursing home after complete recovery and stable condition. Instruction not to remove the airway unless the patient removes it himself is not understood by the nursing staff. Six post-operative deaths have been recorded after a septum operation under GA. The anaesthetist must plan his anaesthesia in such a way that patient recovers complete consciousness at the end or leave the airway in the mouth or insist on surgeon to put small tubes in the nose reaching up to nasopharynx and then pack the nose. These tubes provide airway for emergency (better than no airway at all) and they provide excellent airway at night when the mouth closes and patient does not wake up suddenly choked and has to open the mouth to breathe. Patients are comfortable with tubes.
After planning for lighter anaesthesia at the end I carry out a simple test to find out whether patient has sufficiently recovered. I call it “Gharpure’s test”. Hold the lips of the patient together with both nasal cavities packed. If the patient struggles to open his mouth and succeeds he is in a safe state to be left alone. In patients when the “Safety” polyethylene tubes are put one can test the functioning by listening free breath from the post end (does not touch the post pharyngeal wall and blocks it.) The test can be applied in deeply sedated patients.
In patients who have been given spinal anaesthesia with long acting anaesthetic agents (Bipuvacaine) and surgery gets over in much earlier time (1-2) hours, the effect of the spinal continues for another 3-4 hours. The anaesthetist must instruct the nursing staff about hypotension continuing in postoperative period and its treatment. So many anaesthetist blame the drug. Death has been recorded in the postoperative period. Patient’s blood pressure during surgery is attended to during surgery by the anaesthetist and after surgery the patient is left all alone without instructions.
In smaller setup the commonest cause of postoperative deaths is inadequate reversal of muscle relaxant. Firstly no patient should be shifted from operation table if there is any doubt about his inability to breath. A conscious patient is not a guide for incomplete reversal. A restless patient is always due to hypoxia and not because of pain. A serial B.P. check up every 5 minutes must be done. A rising B.P. is surely sign of incomplete carbon dioxide elimination even though the patient appears pink. A patient who needs assisted respiration in postoperative period with bag and mask needs intubation. A patient who allows IPPR after reversal needs the IPPR.
In all patients with prolonged surgery or toxic patient the presence of qualified doctor is a must. Restlessness in postoperative period should not be translated into pain after surgery but the relevant cause must be found. All patients in whom Lasix was injected during or immediately after surgery, a catheter must be placed in the bladder. Sometimes even a qualified doctor may not be sufficient to understand the cause of restlessness and anaesthetist or operating surgeon must leave instructions rather than testing the intelligence of the house officer.
A diabetic patient on insulin must be under corrected and a small hyperglycaemia accepted rather than hypoglycemia. Covering alternate bottles of glucose 5% infusion with 10 units of soluble insulin is a better plan. Similarly patients with drugs for hypertension given after patient recovers completely and BP checked.
Infants intubated must be closely observed in postoperative period for
Good lusty cry and not a progressive hoarseness
Restless which is mainly hypoxic unless proved otherwise
Dusky colour of skin or mucous membrane. The commonest cause is laryngeal oedema and it calls for immediate treatment and preparation for tracheostomy if treatment fails.
Patients operated for major oral surgery like mandibular tumours of mouth and tongue and tumours of thyroid must be provided an airway at least 48 hours (nasal polyethylene tube with connection) this tube must be removed in the presence of the anaesthetist with all preparations for emergency intubations and IPPR or if found necessary do a tracheostomy. Instances of sudden death in postoperative period are witnessed and documented in such cases. A tongue sutured also prevents falling back of tongue in infants or cases of oral surgery.
All diabetic patients must be converted on soluble insulin regimen if the surgery is major. For minor surgery if the patient is settled on antidiabetic treatment should receive the treatment till previous day and on the day of the operation alternate pint of glucose 5% to be covered by injection Insulin 12 units subcutaneous. The patient goes back to his routine after he starts his oral feeds.
All hypertensives may continue their drug treatment till previous day and after BP check in the morning a dose of nifedepine 10 mg orally under the tongue may be given to check the sudden rise post operatively. All thyroid patients either receiving treatment for hypo or hyper must continue till the day of the surgery. Beta-blockers for thyrotoxicosis must be continued and noted and be informed.
Cases are better worked up by senior surgeons
The situation of postoperative care in smaller nursing home is below standard. Sometimes the operative surgeon is the only resident doctor. In others the theatre sister is the only experienced member in the nursing home. The staff in the ward can hardly be trusted. The best plan is to see that the patient recovers completely on the operation table, the anaesthetist or surgeon stays back till the patient is completely recovered. Some of the most dangerous situations in smaller nursing homes are:
-A major operation done with unstable cardiac and respiratory system
-Patient returned with an airway deeply anaesthetized
-Patient operated for septum with both nostrils packed and no airway provided.
-Long acting agent used for spinal is usually blamed for post operative hypotension which remains unattended.
-Toxic patient with persistent hypotension
-Partially recovered patient from muscle relaxation
-Patient under hypothermia
-Patient operated in oral cavity not recovered fully and no airway provided
-Infants who have been intubated
-Patient operated for upper respiratory tract obstruction.
-Patients on treatment for diabetes or hypertension
-Moribund patient with CVS and RS instability
Patient with previous MI
-Patients heavily sedated, operated under local, suffering from chronic bronchial asthma or chronic severe emphysema.
In the beginning one can expect help from a senior surgeon
In private practice the problems with senior surgeons are minimum. Contrary to popular impressions, they are a great help in preparing the patient and in all stages of anaesthesia. An unscrupulous person is immediately recognized and can be avoided in future. The senior surgeon can tell from his own experience and having worked with senior anaesthesiologist can guide the anaesthetists. They have fair idea about the patients condition during anaesthesia they can recognize from the tissues and the movement of the anaesthetist that something is wrong. They will volunteer help. They from their experience can judge the recovery of the patient. If they suggest that patient is not fully recovered (especially from muscle relaxant effect) it is better to believe them and observe the patient for sometime. The unscrupulous and the junior surgeons should be watched carefully. Beware of surgeons in other branches like dentistry, ophthalmology who are not conversant with anaesthetic complications and hence will be of no help if you are in difficulty.
It is an unrecorded statement that senior surgeon and a senior anaesthetist is the best combination. Senior surgeon and junior anaesthetist or vice versa can be a good workable combination. But a junior surgeon and a junior anaesthetist is a dangerous combination unless proved otherwise. The last combination, both are over confident.
Having worked in teaching hospital after getting the master’s degree gives immense confidence (over confidence) in both surgeons as well as anaesthetist and hence the maximum accident take place during this period. They tend to forget the gravity of the surrounding in which they are working.
Premedication schedule never works due to many variables
Premedication in private practice does not work except with the first case in the morning when anaesthetist and surgeon work at the same nursing home. The scheduled time is disturbed due to:
- Transport difficulties
- Either the surgeon or anaesthetist delayed in the previous case
- Patients relatiives not present
- Patient sent for special exam for ureteric stone or some X-ray investigation needed
- Delay by the theatre staff, equipment
Hence one can depend on premedication on the 1st case only. The rest of the schedule has to be conducted with IV premedication + inductions. Injection Atropine, which was prescribed ½ hour before, does not help in modern practice. It was a must for open drop ether anaesthesia where suppression of salivary secretion was essential. Injection atropine of dryness and some may even start thinking that some extraordinary complications is taking place due to drying and rapid action of the heart and feverish sensation. The olden days premedication for stealing the thyroid in thyrotoxicosis do not apply as they are never taken on table unless sympathetic activity is totally suppressed with anti thyroid drugs.
With IV medication one is assured of
Full administration of drug in system (leaky syringes used by nurses)
Only one injection prick patient feels. This is important in children, as they are very uncooperative for the 2nd injection.
Premedication for infants either by oral or by injection has to be given by ½ hours before induction is by inhalation method. Delayed action like I.V. atropine may not act immediately and appearance of secretion due to endotracheal tube narrow the air passages by secretions.
For patients who are anxious a 10 mg. Diazepam at night or even a tab of diazepam early morning will alleviate the problem.
In patients where induction dose of Thiopentone is likely to be dangerous heavy premedications or basal narcosis is a must, like mitral stenosis patients. Avoid atropine for tachycardia it produces. In very sick and poor risk patients it is better to avoid any premedication.
In some public hospitals the order of patients to be taken for surgery is not known and hence the ward sister gives the injection atropine to all patients at 7.30am as patients are scheduled for surgery at 8.00am (which normally does not start till 8.30 or 9.00 am). The system is followed for years together as anaesthetist insist on atropine ½ hour before. They do not mind delaying the induction till ½ hour is over after injection of atropine is given. I do not understand the rationale behind this plan. Is it because you do conduct less cases in the day and leave early for home? Or is it to show your domination? Nobody is bothered about the suffering of the patient.
Vagolytic action of atropine in pharmacologic doses to prevent vagal arrest is doubted and hence insistence of giving it ½ hour before surgery is sheer ignorance, as IV atropine acts immediately it can certainly replace IM as drying effect is not necessary for IV induction and intubation. If it is given that the 1st drug to be followed by Thiopentone or even mixed with thiopentone (sometimes produces precipitate which dissolves) also acts before scoline and prevents the Cholinergic effect of scoline.
In one infant for congenital cataract the surgeon had prescribed atropine drops in the eye. He did not order oral or sub cut atropine. On arrival we found that atropine drops had produced complete systemic effect with facial flushing tachycardia and dry mouth. Induction with open drop could be take up immediately without injection atropine
Premedication Schedule – never works in private practice except the first case. As you are likely to be delayed, surgeon’s arrival, preparation of OT due to previous operation. Read more on this article...
Preoperative examination and evaluation may not be possible
Even if the pre-operative examination is not possible one should try to get as much information from the surgeon or the patient as one is preparing for anaesthetizing the patient. Simple questions to the surgeon like:
What is the nature of the surgery? (This lets the anaesthetist know about the surgeons plans or length of time likely to be taken.
Anything positive (physiologically abnormal) found in the investigations.
Any illness for which treatment is continuing like diabetes, hypertension, hypothyroidism, the dose patient is taking, how long, nature of drug like tablet or soluble.
Dentures if any if not inspect the oral cavity, colour of tongue any shaky tooth. After reassuring of safe anaesthetic technique one can mention how he will be kept comfortable either by injection, local or general and what will he his state at the end of surgery.
Any instruction during surgery (if no sedation of G.A.) or in the postoperative period.
All this information can be had by the time you are preparing and waiting for the surgeon’s arrival in the operating room.
If one disagrees with the investigation reports or any new finding must be narrated to the surgeon in his room rather than in the presence of the patient.
A patient expressed surprise as to how he was not asked to keep blood-grouped and cross-matched when previously it was needed. The surgeon did not know about this history and laughed it off. Luckily on the operating table there was not much bleeding. The patient’s relatives gave history of recurrent nasopharyngeal fibroma, while the surgeon had diagnosed as a simple polyp.
Another patient refused anaesthesia as blood was not kept ready. Luckily the surgeon on the previous operation was accompanying and he had given history to the operating surgeon. The surgeon had to reassure him that if there is bleeding we have the equipment to stop it. The patient had dilatation of urethra for stricture and he bled every time after dilatation and he needed transfusion. The attending surgeon explained that he had no cystoscope and that is why he had brought the patient.
A doctor patient gave history of a cardiac arrest during a previous operation and hence wanted to know the details of the procedure of anaesthesia. On further questioning it was found that the incidence occurred in a dental chair under ethyl chloride anaesthesia and patient was reassured that we are not using the same drug.
Patient gave distinct history of G6PD deficiency, prolong scoline apnoea, sensitivity to local anaesthetic agents. Some volunteer the information and from some one has to extract information.
It is better to go through the X-rays and reports and if any doubt the query should be raised before anaesthesia or surgery. A male patient of 13-14 years was scheduled for removal of nasal polyp. Doubt was raised whether the senior surgeon has seen the patient. Even after expressing that a nasopharyngeal fibroma has not been excluded the junior still insisted that it is a usual polyp only. On removal of a part of the polyp, when patient started bleeding the surgeon was prevented from proceeding further and packing the nose only was done. The senior surgeon was called who on post rhinoscopic examination certified and confirmed the diagnosis of nasopharyngeal fibroma.
A patient was scheduled for plating femur. Casually asked for X- rays. Only AP view was shown. The surgeon was asked whether other view was taken. The surgeon who was over confident that it was not necessary. On opening, the # line which was single without displacement showed multiple # of the shaft running parallel which could have been detected if any other view was taken.
The time to understand the situation and find the solution is very short
Sometimes you can come across a surgeon who only knows the knife and the organ he has to examine and the sole purpose is earning and not the welfare of the patient on has to be conscientious. To quote a case a patient was scheduled for micro laryngoscopy by a junior. On reaching it was found that the M.L.S. was for a nodule on the cord. When enquiry was made about the age and other medications, the patient was receiving it was revealed that the patient was on regular treatment of mitral stenosis. The patient gave history of dyspnoea, mild exertion. In this case on advice the surgeon and the Physician was questioned about the hoarseness due to enlarge left atrium causing recurrent laryngeal nerve palsy and the propriety of undertaking such a dangerous surgery in a small nursing home. The physician and surgeon were trying to convince me that he will take only 1 minute it was agreed upon to give one small dose of scoline after safe medication with Thiopentone and diazepam inflation with 100%. The surgery was terminated with examination (which was not necessary). In such case dealing with unscrupulous and ignorant persons one should decide to walk out. While in another case of compensated mitral stenosis with a history of 5 pregnancies. No dyspnoea on exertion (walking 5 miles from the village to bus stand). No previous history of dyspnoea, cough, blood in sputum. No oedema or ascites. G.A. was given in a small nursing home for hysterectomy with an understanding between the patient and the surgeon that if any thing went wrong they would have to shift to a bigger hospital. In this particular case patient was refused anaesthesia in the big public hospital after full investigation and the senior anaesthetist walking out on arrival knowing the diagnosis. The only precaution one has to take is to treat the case as of mitral stenosis for induction and maintenance.
Read more on this article...
You may be called upon to give a helping hand
When all set at your end, you can help all others in the theatre towards the well being of the patient and speeding up of the surgery. Your eyes gradually get trained to the extra needs of the surgeon, the nurse or even the ward boy. You start working like a team. If the ward boy is busy helping the nurse or the surgeon, you may be called upon to tie the surgeons gown, provide the gloves etc. If the nurse is busy preparing the trolley, keep a watch on her. Remind her of the sponge/swab count after cleaning the used up sponges and swabs. If the nurse is new you can instruct her about the surgeons requirements. In case you are early in the theatre, have a cursory glance at the autoclave labels on the drums, keep a watch on the time taken by the nurse to wash up. It should take at least 3 minutes. Watch the draping technique. If there are any observers for the surgery make sure that they follow proper asepsis procedures. Advise observers to keep out of the way of the operating room equipment and personnel. Over time the number of people that you need to keep a watch on will decrease. Arranging the theatre light, checking malfunctioning equipment (cautery machine, suction machine, microscope etc.) and correcting minor faults may become part of your duties. Cautery burns may be avoided by observing the person attaching the neutral pad to the patient. Check the label and contents of all IV fluids (for foreign matter, fungus etc.). Check the blood groups and the cross match reports, check the bottle of blood for clots, the colour of the supernatent serum for hemolysis. Check the fluids (normal saline, distilled water, autoclaved water) supplied to the surgeon during endoscopic surgeries. Check all the drugs given to you by the nursing home during the surgery. Safe shifting of the table and removal of the tourniquet must be supervised. Keep the notes during surgery and enter them in your record book if you notice anything unusual. Recording of the tourniquet time, time of the birth of the baby, timing of the drug administered, quantity of fluid administered is a good practice. It may be of help to the team or patient.
Read more on this article...
Help may not be forthcoming as each one is busy with his own job
In most of the nursing homes apart from the operating surgeon and anaesthesiologist the only staff is operating theatre nurse, ward boy and for major surgeries you may find a junior nurse to assist. Sometimes even this minimum staff may be missing and the help comes from the, sometimes surprisingly competent, sweeper of the nursing home. So it is presumed that you are alone and managing everything at your end. You may ask for various things and you are informed of their locations. After arranging your equipment you are supposed to put up a drape and place the scalp vein or needle. Over time you will become more familiar with the particular nursing home. A different nursing home will require you to start over again. You have to take the BP of the patient yourself, use your own tourniquet and set up a drip, taking into consideration the nature of the surgery and the position of the patient.
All the above can be learnt by accompanying a senior anaesthesiologist working in small nursing homes. Observe and ask any questions but do not try to help the anaesthesiologist (unless he asks for your help). This will train you to work single handed. Even in a major case the routine remains the same. You may request the surgeon to help (if needed) before he washes up for surgery.
Your equipment is handled by you alone and no one can help you
Make sure that your equipment is full and complete and you are capable of conducting any case even in a village. You must be fully equipped with all your drugs for induction, maintenance, reversal, and also for resuscitation. Do not depend upon the nursing home to provide you with anything.
One of my colleagues never carried distilled water vials with him. One day he was faced with no saline, no water to dissolve Thiopentone. He probably used boiling water from the sterilizer and no wonder all patients developed hyperpyrexia.
When you paralyze a patient with long acting muscle relaxant you must possess the necessary prostigmine with you. Similarly if you intend to give spinal a vasopressor must be in your possession. While anaesthetizing an asthmatic patient check the immediate availability of aminophylline, cortisone, adrenalin etc. and the spray he may be using (salbutamide).
Laryngoscope
Laryngoscope is the most important piece of equipment. It must be in perfect condition. All spares must be readily available all the time. A spare bulb and pair of batteries (unused) must be at hand. Those who use rechargeable batteries, a note of caution, when the batteries are nearly discharged the bulb can fade away within seconds. A pair of batteries must always be in stock. The repairs and checking of all parts must be mastered for use in emergency. If the bulb is not working, check the following:
Change the batteries.
Check all contacts points and clean all the metal contacts with rough hard object or sandpaper if available.
Check the bulb by unscrewing from its place and checking it on the spring of the metal contact on laryngoscope handle and touching the body of the bulb to the body of the handle. If the bulb lights it means that laryngoscope handle, batteries, and bulb are O.K.
Clean the seating of the bulb in the blade and re-check the contact point on the blade and polish the same with sandpaper or even a metal file. The seating of the bulb can be cleaned by a needle and a drop of ether. Allow it to dry and replace the bulb.
Check the bulb. If it shows blackish discoloration change the bulb.
The insulation between the bulb body and contact points is only a small piece of paper, which gets wet while cleaning with water. Disengage the bulb and let it dry. Try to use it again. If it does not, pull the metal contact by a fraction of a millimetre. After constant use the insulation (paper) becomes useless and the contact and the bulb body touch directly and the bulb is short-circuited.
Checking the handle is easy. Unscrew the cap of the handle. Check the tension of the spring. Dry the handle from inside. Polish the contact of the spring with the metal body of the battery. Thus all metal contact points must be checked and cleaned of deposition of copper oxides. After use detach the blade, screw the bulb (if it is loose) and wash it with soap and water. The handle does not need cleaning unless smeared with blood during use in a difficult intubation. Minor points in repair of the laryngoscope must be known. Nobody teaches nor is it given in books. Check the light after cleaning.
If possible keep a spare Laryngoscope, cells and a bulb.
Extra long blade and special laryngoscopes can be useful.
Lastly do not loose your head. Insert the un-lighted blade in the patient’s mouth, give the correct position for intubation and pass a tube blindly. If the intubation for the same reason is difficult you may fail, otherwise in 90% cases you will succeed and carry the day.
Endotracheal tubes
The length of the endotracheal tube (ET) must not be longer than 2” of the size required. Longer ET may cause endobronchial intubation. The ET must have a nose worthy connection fitted permanently. So that it can be easily connected to the unidirectional valve for IPPR. Longer ET comes in the way for operations on the head and face and intra-oral surgery.
All tubes must be boiled for 2–3 minutes before use and re-checked as some debris only becomes apparent after boiling. The hard plastic tubes should be kept in warm water to make them soft and non traumatic (for nasal intubation).
Always check the temperature of the ET after it is taken out from the boiling water. Allow it to cool. Apply lubricant jelly after the tubes have cooled. In extreme emergency cool the tubes under tap water before intubating.
Keep all sizes of ET handy all times including OO size for new born resuscitation. Always have 3 sizes of ET ready. Apart from the proper size that you have selected have a smaller size and bigger size ready. Do not fumble at the last moment.
Special nasal tubes of sizes 6 mm to 10 mm must always be available for emergency use in failed oral intubation.
All endotracheal tubes must be secured with a good strip of sticking plaster. In cases of patient with beard or patient in prone position, it must be secured with additional bandage going round the neck. Chances of slipping of tube (which are quite high) are thus prevented. In case of infants it can be a disaster. In cases of children never pass a cuffed endotracheal tube. Avoid using cuffed tubes in cold cases. If at all used, inflate the cuff balloon yourself.
Other equipment
All tubes should be fitted with Noseworthy connections of proper size so as to avoid searching for a connection and fitting of wrong connection (small) in a bigger endotracheal tube (by the assistant or ward boy) the Nose worthy connection takes up the unidirectional valve directly and does not need any other connection or catheter mount. In some cases of facio maxillary surgery (cleft lip and palate) use the Magill’s connection going to the endotracheal tube (especially the Oxford tube) with extra length of arm going out. This makes the job of the plastic surgeon of fitting the Boyle Davis gag easy and leaving some length of connection for fitting Ayre’s T piece.
Bellows Unit: Always open the bellows from the lock instead of fumbling. Never keep cotton swabs and gauze pieces on the table as they are likely to get sucked in and block the inlet of the bellows and after a time may not allow any air in the bellows. These foreign bodies are not easily spotted unless you expect them. If the rubber shows signs of perishing get it changed immediately.
It is always preferable to use the bellow unit with unidirectional valve situated under the bellows than separate disc valve set. Like in Oxford inflating bellows. It makes the equipment lighter.
Disconnect the delivery tube whenever one leaves the bottle or the patient. Always keep the palm loosely over the lid which keeps you informed about the respiratory rate and volume and it steadies the vaporizer. So many accidents have been recorded due to aspiration of pure liquid ether in the respiratory passage which results in pulmonary oedema and death. At one time this technique was supposed to be the safest. However if taken lightly it can cause deaths.
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:
General condition of the patient. Emaciated, toxic patient, hyperthyroid patient, patient with pyrexia, severe anaemia, and previous operation scars.
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.
