Saturday, March 27, 2010

Where we are at

I recently spent a few days in Bloemfontein. This would not have been my first choice of holiday destination, but it was the venue for the annual South African Society of Anaesthesiologists (SASA) congress. I enjoy attending meetings and congresses because it gives me a chance to catch up with the people who taught me anaesthesia and who have subsequently left state, or worse, the country.

Having spent 5 days with these people, I have some observations.

Firstly, we are so far behind the curve (in state practice) that it is not even funny. I attended a mini course on transesophageal echocardiography (TEE), presented almost entirely by ex Free State Universtity consultants who are working at a cardiac surgery centre in the UK. More on the TEE later..

We suffer under a huge burden of rheumatic heart disease, with resultant dysfunction in mitral and aortic valves. My surgical colleagues have a single response to this disease - replace the valve. Apparently, the standard of care is to repair the valve. Because our surgeons don’t repair, we have not been trained to assess valves adequately with the echo. So, hopefully I can now give some input and suggest valve repair. They also dope patients for trans-apical aortic valve replacements - a procedure which is exceptionally high risk, given that these patients are too sick for routine aortic valve surgery.

Secondly, we have lost so many brilliant minds in the field. Looking at a large group of anaesthesiologists, the most prominent thing for me is the age gap. There are lots of young guys like me (<35) and there are lots of people in their late fifties and up. In between, there is nothing. Where are all these anaesthetists? They have gone - Canada, United Kingdom and Australia. One hospital in Canberra currently has 5 consultant anaesthesiologists who are South Africans, all from Jhb. This is a big problem for us and reflects the problems in this country. There was much debate about whether they were “pulled” overseas, or “pushed” - General consensus was the latter.....

Thirdly, and perhaps most alarmingly, there is a very high incidence of moonbags. The less said about this, the better.

Saturday, March 6, 2010

Little things

Kids, rugrats, sprogs. All different names for the same entity. And for most of us, cause for the smallest of flutters. You see, kids aren't simply small adults. They have unique physiology and they have given me more grey hairs as an anaesthesiologist than any other patient group.

Having said this, however, I consider myself to be reasonably confident in dealing with anaesthesia for small people. This is born of a large amount of experience - we have a very busy paediatric surgical department and, in addition, perform a (relatively) large number of surgeries for congenital cardiac conditions. So, when I was called upon as a registrar, late one night, to dope a 3 year old boy for a repair of a nail-bed injury, I didn't worry too much. As they say, pride comes before a fall....

As anaesthetists, we dislike poking children with sharp sticks while they are awake, so when we anaesthetise children we generally induce anaesthesia with gas. We explain to the parent that we are going to get the kid to breathe in our gas, and they will drift off to sleep. We also tell them that this is not a painful process and that the child will probably have no recollection of the induction. This explanation falls into the category of "if I say it often enough, someone will probably believe it."

To be honest, every once in a while I can pop a kid off to sleep without it really noticing, but these are few and far between. The fact is, the gas smells funny, and children don't like having things thrust in their faces, especially in an unfamiliar environment like an operating theatre. As a result I usually try to sneak the kid off slowly and surreptitiously (ninja style) but if they start crying or fighting we go full blast, hold them tightly and get it over with as soon as possible.

Unfortunately, this is the situation I find myself in on this particular night. Despite all my cajoling and ninja techniques, this poor child is fighting and kicking. So we switch to the infamous "gorilla style" induction. Hold him tight (anyone who as had to confine a strong 3 yr old will know that this can take 3 people) and go full blast with the Sevoflurane (anaesthetic gas). Sevoflurane typically works in 2-3 minutes especially if the child is taking deep breaths, which they typically are when they are crying. So you can imagine my surprise when after a good 3 minutes of fighting the kid is still wide awake.

"Don't worry," I tell the mom, "he'll sleep soon.." We carry on for another 2 minutes or so - no change. Now I am starting to think about why he isn't going to sleep. I turn around and see, to my horror, that the breathing circuit is not connected to the anaesthetic machine anymore. Our patient must have kicked it off very early in the process. I have spent 4 minutes trying to put the child to sleep with room air. Any parent will tell you that this approach is generally suboptimal.

So I have a dilemma. Do I tell the mom the truth i.e. that I am an idiot, or do I surreptitiously plug it in and carry on? I'm embarrassed to admit, all these years later, that I simply plugged it in. Once the child was actually getting the gas, he went to sleep in about 60 seconds flat. I wonder if the mother noticed. If she did, she never said anything....