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 It will be foolish to say that a particular drug or equipment is outdated in world literature and hence needs to be condemned.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.

Read more on this article...