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:
Tuesday, August 10, 2010
Private Practice- Learning the ropes
Thursday, July 1, 2010
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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Tuesday, June 15, 2010
Cautionary Hints and Tips
Endotracheal tube related cautionary hints and tips...
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
Tuesday, June 1, 2010
Ludwig's Angina and Trismus
This case of Ludwig’s angina dates back to when I was in England. The patient aged 46 years, admitted for chronic dental abscess suddenly became acute and developed trismus. The resident anesthesiologist wanted to secure the airway under topical. My consultant was conducting a mitral valvotomy and left me to help these residents. She was very confident and said that the trismus disappears under Scoline and intubation will be possible. I smiled because in Bombay we were taught that a patient having Ludwig’s angina with difficulty in breathing should not be put to sleep. Since I smiled she knew that I disagreed. My next question was whether they are going to open the abscess from the skin or inside the mouth. She said that she is not aware but quoted a case from the medico-legal magazine where the anesthesiologist was blamed for not securing an airway. Anyway my reluctance was clear and I even asserted that I would not put this patient to sleep. She proceeded to conduct this case. She confidently gave Thiopentone and Scoline and to her amazement the jaw was only partially relaxed; she could not ventilate the patient. The laryngoscope did not reveal any anatomical landmark except a white wall in front. The residents in order of their seniority tried to intubate and failed. The last person to try was house surgeon and the patient by now was jet blue. Luckily he could see the chord separating and pushed the tube down. The dental surgeon opened the abscess which was pointing at the skin. The entire procedure could have been done under ethyl chloride spray locally.
When the consultant returned, and told me the whole story I asked her whether she had ordered a tracheostomy set in the ward by the bedside. She laughed and said the adults do not get laryngeal oedema and complete closure of the airway. Only four hours later the same patient was wheeled into the operation theatre and a stab tracheostomy was done to save his life.
Tuesday, May 11, 2010
Balancing appointments and work schedule is always a challenge
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 10, 2010
Heat in Anesthesia: Reports of accidental deaths
Explosions in the operation theatre...
The patient- a child with vegetative foreign body swollen and soft in the bronchus. The patient was induced with ethyl chloride ether and taken deep in third stage, third plane and handed over to the surgeon as the procedure was expected to take longer than usual. The surgeon started and removed the foreign body bit by bit. O2 was added through the nozzle provided on the bronchoscope. In the middle of surgery there was a bang the surgeon face scalded and hair burnt and the child lay dead. Cause: Explosion due to over heated bulb and oxygen.
In another instance, the patient was induced in the induction room intubated and wheeled into the operation theatre. As soon as the anesthesiologist pressed the reservoir bag he was thrown away from the machine with burns on his hand and the patient lay dead. The reservoir bag was blown to pieces. Cause – Static electric spark causing explosion
During visit to Shrirampur for an ENT camp at the end of the day the doctors had some questions for both of us- the ENT surgeon and anesthesiologist over dinner. They presented me with a case which had resulted in death on the operation table. The incident had taken place during the hot summer days. Patient was male13-14 years old; symptoms were: high temperature 2-3 days, acute abdomen. The patient was induced with ethyl chloride ether after proper atropinization. The operation started after intubation and patient was connected to the Flagg’s can. The patient developed severe convulsions and died after couple of convulsive episodes. They wanted me to explain the cause. It was a typical case of ether convulsion with all conditions contributing to the fatality. High temperature summer days, ordinary operation theatre (not air-conditioned), good atropine action, toxaemia, deep ether anaesthesia good for laparotomy. All these were text book conditions for ether induced convulsions. They wanted to know the method for avoiding this complication. My answer was simple– cool the patient, use ether 2% after Thiopentone Scoline induction intubation and using muscle relaxant and IPPR. In case you can avoid ether use N2O--O2 IPPR with small supplements of pethidine.
Peritonsillar abscess
For severe infections indicating Ludwig’s angina do not give anaesthesia or try sedate patient until the airway is secured under local anaesthesia (topical). Even after treatment (incision) remember that the patient can develop laryngeal oedema. In peritonsillar abscess. In case of a child, keep the child in steep Trendelenburg position; keep the mouth open as much as child can open and put a mouth gag for safety. If possible apply a swab soaked in 4% Xylocaine to the area. Take a very thick aspiration needle attached to a suction tube and put it in the abscess cavity. Aspirate all the pus and enlarge the opening with a curved knife. Never give in to any sympathy for a howling child. Never think of giving anaesthesia or even sedation. In extreme circumstances these children breath with accessory muscles of breathing. Any anaesthesia even simple nitrous oxide, oxygen or sedation results in apnoea which can be fatal.
Flagg's can (Part I)- Reports of incidents involving accidental deaths.
When things go wrong...The new ward boy in the operating theatre was asked to fill ether- full in amber drop bottles and half in Flagg’s can. He did exactly the reverse. The patient was induced with ethyl chloride and ether and when relaxed he was intubated and connected to the full Flagg’s can. The patient aspirated pure liquid ether developed pulmonary oedema and developed cardiac arrest.
Another patient- a child undergoing mastoidectomy with Flagg’s can was kept secured in a doughnut. The surgeon adjusted the position of the head; tilted the Flagg’s can resulting in aspiration of liquid ether. The patient developed pulmonary oedema was immediately bronchoscoped aspirated and lavaged with dilute solution of soda bicarbonate. The patient expired the next day.
On a winter morning when the temperature was really cold, ether was used in Flagg’s can and to prevent the cooling of the bottle it was kept in a water bowl. After the tonsillectomy was over, the anesthesiologist had to attend a telephone call. He left the patient disconnecting the Flagg’s can and instructed the house surgeon to remove the E.T. and do adenoidectomy. During the adenoidectomy it was observed that the blood was very dark. The patient could not be resuscitated.
Cause: The delivery tube was disconnected at the Flagg’s can end which was dipping in the water bath. When the anesthesiologist left, the child aspirated water from the water bath and drowned. Death due to drowning in fresh water.
Flagg's can (Part II): Reports of incidents involving accidental deaths
A junior anesthesiologist in the middle of a tonsillectomy operation broke the K.E.M. bottle which essentially was a modified Flagg’s can. He lost his cool; and put the delivery tube in the stock ether bottle. Luckily the size of the delivery tube was slightly smaller than the opening of the stock ether bottle. The patient after few episodes of hypoxia was able to come through the operation when the delivery tube was taken out from the ether bottle. The second patient managed to survive the operation but later lost his life when the anesthesiologist was doing the oropharyngeal toilet; the delivery tube went in the bottle and dipped in the liquid ether. As a result the patient, a child, aspirated liquid ether and had pulmonary oedema – leading to cardiac arrest – finally death
Another incident involved a case where the surgeon in a mofussil (non-urban) hospital induced a patient with open drop ether anaesthesia. The anesthesiologist looing for the modified Flagg’s can (KEM bottle) found out thta it was being used at another table. The anesthesiologis put the delivery tube directly to the ether stock bottle and asked the ward boy to look after the patient and went to wash up only to find the patient dead. Cause: There was no place for the air to enter the bottle.
In yet another incident, the Flagg’s can was used for an infant with cleft lip. Since the tidal volume is small, the patient kept breathing his exhaled air. The end of the patient terminated the surgery.
