Reporting your observations: Beyond the call?

A senior urologist had taken a patient aged 82 for cystoscopy. The surgeon was in some doubt about why he was doing the cystoscopy, but since the patient had complaints he did not want to miss anything serious. I was about to cannulate a vein for anesthesia on the left forearm which was abducted on a arm board when I noticed a thumb sized vein on the chest wall. I wanted him to see it. As soon as he saw it he know that he had missed something big. He removed his gloves and put his hand on the upper part of the abdomen. He later confirmed that it was a big gastric carcinoma with complete blockage of the vena cava. Needless to say, the scopy was abandoned.
My point is that your should report your observations to the surgeon. I asked my students whether they narrate their observations. Some did not respond, some said that it is not our job. In my opinion one of our duties is to guard the patient’s interest; if you observe anything significant report it since silence could harm the patient. When I taught, I presented my private practice cases to my students as problems, I asked them whether they would proceed with anesthesia, refuse anesthesia, or would they like to know what happened to the patient. I made them think about it and discuss it in the next meeting. In this manner they learned much more than what text books could teach them.

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#11-15: Private Practice Anesthesia- Do’s and Dont’s

11. Get acclimatized to the nursing home. Find out whether things and injectables are available and where they are stored.
    
12. Palpate the vein before puncturing or cannulating. Ask the patient as to where he is taking the injections. Choose the site of puncture depending on nature of operation and the position of the patient during surgery. This is your lifeline. In obese and small children spend some time to find a vein. Do not use the vein on the side where arterio-venous fistula is created.
    
13. Listen to the patient his choices and thoughts. Work according to his choice if possible or try to convince him what is best for him.
    
14. Children for IV puncture usually cooperate well in sitting position and talking to them explaining what you intend to do. Some children may not cooperate. Avoid premedication by injection as far as possible.
    
15. Plan your anaesthesia in such a way that patients are fully conscious as far as possible at the end of procedure. If not make sure they are at least rousable. If the patient is deep observe before sending him back to the ward. Before releasing the patient, try the “Gharpure sign”--The patient on closing both nose and mouth must involuntarily open the mouth to breathe.

#16-20: Private Practice Anesthesia- Do’s and Dont’s

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