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.
Tuesday, May 11, 2010
Balancing appointments and work schedule is always a challenge
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.
