Tuesday, December 29, 2009

Comfort Zones - or "A day in the life of an anaesthetist who hasn't gone away for the holidays"

A recent blog by one of the sublimely funny guys I follow on Twitter ( highlighted the joys of living in the big smoke during the Christmas holidays. It feels like the vast majority of people (who have the wherewithal) simply disappear to the coast, and the streets echo with the sounds of house alarms going off, howling dogs and the incessant ring of my cell-phone.

Now don't get me wrong, being in the service provision industry (I provide immobile, amnestic patients to surgeons), I am well aware that no work = no pay. However, I didn't stay in town to work my a*s off. I'd like to go to my salaried gig, do as little as possible while still looking productive, and then go home to play in the pool with the kids, drink good red wine, and wait for the new year.

Unfortunately, my 'phone, and my colleagues have other ideas. Take today as an example. There are rumours floating around of a really sick cardiac patient in the local private clinic, and a cardiac surgeon desperately looking for an anaesthesiologist to dope the poor sod for his valve replacement. I get a small spike in adrenaline, because this patient, from what I've heard, is practically sitting down to tea with St. Peter. But never fear, my senior colleague is going to do the case. Relief washes over me, until I discover that said senior colleague has a bad case of Bombay bum, and is man-down. Now the job falls to me as the next most senior cardiac anaesthetist.

So what, you say, you are a cardiac anaesthesiologist, how hard could it be? And therein lies the rub. The biggest problem facing me now is not the pre-terminal patient. We get enough of those in our fine ivory tower on the hill. No, my problem is that I am going to be way out of my usual haunts. New hospital, new surgeon (although widely respected), and unfamiliar team = something approaching palpitations.

We take for granted simply knowing where things are. In our hospital, every OR is uniformly equipped and stocked. i.e when I open the third drawer on my trolley, I know exactly what I'll find there. Now I am stuck in an unfamiliar environment, and have to ask the long suffering anaesthetic sister where everything is. It doesn't help that I, being blessed with a Y chromosome can't even see the things directly in front of me. All of this conspires to create a zone of acute discomfort for me, which I'm trying desperately to hide behind a veneer of confidence. It doesn't help that I have never done a private cardiac case before.

Fortunately, the case goes well, the training takes over, and at the end of the day, a cardiac dope is a cardiac dope whether the walls are white or green. I hope no-one noticed my hands shaking....

Saturday, December 26, 2009

Situational Awareness

When people find out what I do for a living, I usually get one of two responses. Firstly, someone will always tell me a story of how their friend/relative had an operation and the anaesthetist’s bill was so high, yadda yadda etc etc. The second response is usually, “so are you there the whole time while the patient is asleep?”

This represents an indictment on our discipline. Not that we are bad doctors (for the most part) but that we are bad at letting people know what it is that we do. Some folks don’t even think that we are doctors. (we are, by the way. I have 10years training). The analogy I use to illustrate what it is we do, is to think of the anaesthesiologist as an airline pilot. We get very busy at the beginning and the end of a case, don’t do too much in the middle, but if something goes pear-shaped, you’d better hope you have a good one.

To be honest, 99.9% of the time, nothing happens. The patient goes to sleep uneventfully, and wakes up comfortably, and in-between we maintain a state of alertness, which I term “situational awareness” (also borrowed from the aviation industry). I never leave theatre while my patient is under anaesthetic. I don’t necessarily always look at the monitors, but I know that I can detect the slightest change in parameters. A study done in specialist anaesthesiologists demonstrated that we can detect, using our ears, a 3 beat/minute change in heart rate without looking at the monitor. I pay attention to what the surgeon is doing (making sure he isn’t trying to operate my patient to death!), monitor perfusion of the extremities by periodically laying a hand on a limb, and even, occasionally have a peek at the Sudoku.

Yes, anaesthesiologists do sometimes do mundane things like reading or Sudoku in theatre. The point is, that we don’t let these interfere with our situational awareness. The good anaesthesiologist is the super calm chap sitting quietly in the corner with half an eye on the goings on in theatre at all times. The best anaesthetists I know, are those who can do this. Then, if anything does go wrong, they move. Quickly. With purpose, and calmly. The anaesthesiologist should be the last person in theatre who panics. I have seen registrars (trainees)who panic when things go wrong. They are then in trouble, because if they lose the plot, they aren’t thinking, and then someone is going to have a poor outcome.

So the response to the first comment people make is, in fact the same as the response to the second one. The reason we are expensive (and I know some guys billing takes the piss) is because you are paying for that level of skill and training. You should hope your anaesthesiologist never needs to use the full level of their skills.

Monday, December 21, 2009

In the beginning...

This is the first of what may be many posts. I am an anaesthesiologist in a large academic hospital in South Africa. Blogging has always appealed to my narcissistic side, but until recently I have not felt called to set finger to keypad. However, a friend referred me to another blog and reading that I realise that I may well have a contribution to make...

I certainly have some interesting tales to tell from 10+ years in state practice in this country, and can identify a lot with some of the experiences related by Bongi at the above blog. So we will see what comes up. Hopefully I won't say something that will get me fired..