A very important relationship

It matters a lot to us who is at the “head end” of the patient as our anaesthetist (anaesthesiologist) and recently I have been thinking on just how much this matters. I’ve moaned a little bit about anaesthetists on this blog, and I do think that they are for the most part not funny, but much like a decent sports bra or proper toilet paper, you only really appreciate them when made to do without. There are lots of jokes about us and them and we like to pretend that their job is easy (inject the white stuff, breathe the gassy stuff, inject the paralysis stuff, done) and they think we are stupid for an example see this youtube video of the Orthopaedic registrar talking to the on call Anaesthetic registrar.

During a nice straight forward gallbladder list I was left to do last week (with the consultant available if I needed him obviously) I had an unknown anaesthetist whose affect and manner seemed at odds to the usual capable and competent anaesthetists that I am used to. Five minutes into the case and she was flapping, something about the pressures somewhere being too high. I was mid dissection of the fat (this case was a BMI 40 gallbladder) that was sticking the duodenum onto the gallbladder and this, although straight forward, requires attention that you don’t burn the duodenum or make anything bleed. I clearly asked her “do you need me to stop and let the gas out?”. “I don’t know” she said “I’m not sure what’s wrong.” So I stopped and we let the gas out and waited for her to get control and I felt anxiety wash over me as I watched her flap and panic.

The anaesthetic nurse wisely exited the room at this point to call for the anaesthetic consultant who had popped down to the coffee room for lunch. He arrived (he is the coolest and best anaesthetist we have as it happens) immediately realised that the tube was in too far as the lady had a short trachea, pulled it back a bit and we carried on. It was all pretty straightforward apparently and Dr Cool said he wouldn’t have interrupted the operation and that Dr Panic Merchant was new and inexperienced.

As the surgeon operating you carry the responsibility, it’s your patient, you know them and their husband, that they have a wedding to go to in March and are going to Spain in 4 weeks, they know and trust you. The deep fear that this event put in me that something was going to happen to my lady and that I couldn’t control any of it was terrifying. The next 2 cases were similar with repeated flapping from the top end and the nurse having to reassure me that it was all ok as she dealt with the minor problems this new girl could not resolve. I was nervous by the end of the list, I didn’t trust the local anaesthetic dose she she’d given me, I didn’t trust the antibiotic dose (yes, yes smarty pants readers I made a hole in one and spilt a tiny bit of bile) that she gave and was stressed out for the whole list.

Usually I am blissfully unaware of problems unless I need to be made aware and the communications between us and them are smooth and calm. Problems a good anaesthetist tells you about are: to stop operating as the patient needs chest compressions (happens during ruptured AAA’s etc) or that they need you to stop so they can catch up on blood loss and clotting products, if the BP drops suddenly they will ask if you are squashing something important (IVC, heart, liver), to ask if you have just had a big bleed (usually we will have told them already) and to ask how is it going.

In turn, when we ask how it is going and there are concerns they use some sort of ambiguous answer that will reassure us, it is not like lying but avoids telling us the full extent of the bad news until we have finished. For example  “good, she’s making urine and her haemoglobin is ok”. The truth is she has a pH of 7.15 and has received 3 units of blood to make her haemoglobin ok but there isn’t much point in telling me that when I am elbow deep in a narrow pelvis and can’t do much about it. It just makes us worry, distracts us and that is bad for operating. The fact I am asking how it is going, is an indicator that I know it is not going well at the physiological end. A friend of mine who anaesthetises for big cases tells me that a huge part of her job is to keep the surgeon happy and focused and unaware of problems unless they need to know or  until the case is done. 

So following last weeks nonsense with the new girl, I am full of love for our usual anaesthetists. I am grateful and impressed with their smooth and easy anaesthetics (they could be a bit quicker in the anaesthetic room though) and have a new understanding of the relationship. Many of my bosses have great anaesthetists, one or two have less great ones, it’s impossible to influence who you end up with but I hope when I grow up I get one of the greats.

It probably is harder than it looks, they just make it seem easy 'cos they're that good

It probably is harder than it looks, they just make it seem easy ‘cos they’re that good

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