Friday, October 31, 2014

So you wanna be an anaesthetist? Pre Op Assesment Part 2

Ok.. now you are seeing the patient. Why? Obviously the meeting is for rapport but at the same time to discuss the options of anaesthesia available to the patient which is appropriate to the procedure. Sounds like a straight forward job right? Just refer to the guidelines in assessing the patient
Its not that simple. When i was doing this job in my early days, my focus was on the well being of the patient, his suitability, his risks and the consent. It was only about my job and role. Pretty isolated.We were to assess patient's history, medical problems and their compliance to their medication, basic effort tolerance review, airway assessment etc. A review of the investigation was a must and it was a BIG point in HKL then that if the investigations are not ready we will not review the patient.(which has its advantages but that is never the point!!)
What i discovered through the years is its more than that. Anaesthetist are supposed to be the brilliant bunch. Therefore, the depth of knowledge is important and it is not limited to anaesthesia but holisticly. Ie its not enough to know what surgery but the whole process of the surgery itself should be well known from the actual surgery to their recovery in ward. That is why we are perioperative physicians 
Serious! Thats how much an anaesthetist should know. Experience is virtue and should not be compromised for whatever reason. I reckon it should be a pre-requisite for anaesthetist to do compulsory medical and surgical posting before being admitted into the programme. It is a good idea to know whats on the other side and by understanding the whole picture, any miscommunication can be avoided.( i will certainly blog about this in more detail!! haha interesting stories to tell).There was a time during my infancy days that what i care was only when they were in the OT - which is a totally no-no. 
Knowing what surgeon does to the patient is important as there can be times during the surgery that they may request funny things for us to do. EG in PCNL, the urologist may ask us to halt the ventilation when he is puncturing the kidney. THis should be momentary but sometimes it takes more than 5 minutes for them to do so and in due time causing a lot of stress on my side! haha 
I remember when i was a junior MO having an argument with Mr Rohan (Consultant Urologist) in Selayang during his PCNL procedures because i thought it was not right to stop the ventilation for so long! hahaha No wonder he was pissed off when i continued to ventilate. It is through experience that i learn, we can assist the surgeon to make things easier and more convenient for them. eg in off pump CABG while doing the circumflex graft ; sometimes it is necessary for me to intermittently stop the ventilation to ensure my surgeon suture the graft perfectly. This will in fact reduce the possibility of post op graft complication. 
In government hospitals, some surgeons view anaesthetist job is mainly to cancel the cases until proven otherwise.In a way this can be true as any patients not optimized will be cancelled! Unfortunately, the decision to cancel are often  unilateral without a professional colleague to colleague discussion. The word "optimization" can be subjective. The long line of listed patients can be a burden but cancelling and rescheduling is troublesome for the patient. I am glad my training in anaesthesia in multiple centres had taught me how to properly manage a patient. It is not about the anaesthesia so much but more about the quality of care and patient satisfaction.Imagine being the patients themselves, having cases cancelled because the young ASA 1 patient with the pottasium being 3.0 for an I&D case is ridiculous! 
I know a lot of anaesthetist can be really petty about trivial things but by making decisions unilateral does not help the situation. Of course, i have come across surgeons who are interested in just doing their cutting with no regards to the patient's general condition! However i am sure these type of surgeons are a dying breed. 
Anaesthetist i reckon should lead the way to educate teamwork care in a respectable manner. A lot of criterias should be considered before deciding not to proceed with the case. It has to do a lot with communication. How many times have we heard shoutings between a male surgeon and a female anaesthetist arguing about case being cancelled? Haha However, it is not bounded to the gender or place, as when i was abroad these issues are similar! 

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