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Topics - jafo1964

General Discussion / to anaesthetize or to say no
November 30, 2012, 05:40:30 PM
Just got face to face with a moral dilemma and was wondering what the anaesthetic community would decide largely on this

called into see a 92 year old man who had fallen this morning and fractured his tibia
No previous surgery or allergy or major hospitalisation. Currently he is not receiving and drugs. He may have been on some in the past but progressively discontinued all of them.

Pale looking man , surprisingly had reasonable nutritional status.
He was drowsy, semi-conscious responding to minimal painful stimuli
History of hearing loss - could be the reason for failure to respond to verbal commands
respiration , airway control and pupils were all normal
CVS parameters were stable
He had a pansystolic murmur over the praecordium
RS showed a few scattered creps

Hb was 6.5
Urea was 84 and creatinine was 4.2
Electrolytes were unremarkable with potassium at 5.0
ECG shows old IWMI

Awaiting CT scan, my guess is that it will show nothing significant except for the atrophic changes associated with aging and dementia.

Has a compound fracture of Tibia and there is a steady ooze from the wound

Prior to the fall he was restricted to his room but could move by himself

The family asks if the surgery will set him back to normal

What would you think, say and do

I am awaiting the CT  and ECHO reports but am strongly inclined to advice not to subject this gentleman for anaesthesia and surgery. The risk is high and i am not sure that it will improve the quality of life


General Discussion / CRF with AV fistula blow out
November 27, 2011, 11:54:45 AM
A 60 year old male is scheduled for emergency exploration of a AV fistula blow out at his left wrist. Bleeding has been arrested with a compression bandage
He is currently drowsy, arousable and disoriented
His BP is 170 / 100
His CVS and RS examination reveals nothing of significance
ECG shows LVH with strain
CXR - mild cardiomegaly
His HB is 8.5
urea is 86
creatinine is 6.6
Na is 129
K is 5.5

BT/ CT has not been done

The surgeons want to explore the site at the wrist and will use a tourniquet

Am i justified in using a regional block or is GA the way to go
If sedation is necessary what drugs would you choose
General Discussion / Kinase Inhibitors and GA
November 22, 2011, 03:19:46 PM
Hi all

Have a 65 year old lady posted for fractional curettage and proceed
She is a case of CML, treated and now in remission and is currently on on IMATINIB MESYLATE ( Gleevec)

THe side effects of this drug is quite exhaustive
This pt has an Effort tolerance < 4 METS and is a diabetic with reasonable control

Her history related to coagulation, renal and hepatic function is largely insignificant

Surgery may last 30 mins
I am planning to slip in a LMA under Propofol and Fentanyl
and maintain her under Spontaneous Ventilation with Sevoflurane

Any advices on how to do it better
Any areas i need to focus on

General Discussion / ETCO2 tracing
April 15, 2011, 02:03:52 PM

An ASA 1 patient undergoing GA
Glycopyrrolate 0.2 + Fentanyl 100mcg + IV paracetamol 1 gm
Xylocard 50 mg + Propofol 120 mg +Rocuronium 35 mg
Intubated with 7.5 mmHg oral ETT
N2O 2L + O2 1 L + Sevoflurane 1.5%
Pt on anaesthesia ventilator with TV of 500 ml and rate of 12.
The above picture is the ETCO2 tracing. All other monitored parameters were within normal limits.
After about 15 mins of continuing same line of management the ETCO2 tracing became normal

Is there an abnormality in the tracing or is it nothing to be worried about

A 72 year old hypertensive & COPD patient with a trochanteric fracture was worked up for DHS
HT was controlled with Atenolol 50 mg OD
He had a smoking history of 50 pack years and had bad lungs at admission. The chest physician started him on Nebulized beta2 agonists, steroids and ipratropium.  As no improvement was seen he added IV Methylprednisolone 125 mg tds.
On day3 at assessment,  lungs still had bilateral wheeze and scattered crepitations and his ECHO was normal but for the concentric LVH. ECG was within normal limits and CXR showed tubular heart with hyperinflated lung fields.
Since conversion to GA if necessary would be risky, a CSE ( 2 needle, 2 interspace sequential technique) was planned so that post-op analgesia could be provided with an elastomeric pump infusion. LMWH dose was withdrawn 24 hours before needle placement.
After all the initial set up in OT as per scientific protocol, with the patient sitting Epidural attempted at L34 ISS with 16G Tuohy needle using LORT air technique. Inadvertent dural puncture ensued and the needle was withdrawn. Repeat epidural was done in T12L1 ISS, space identified and the catheter was passed caudad upto 4 cms in space to tip it probably at L23 level. When the catheter was aspirated CSF was noted. Uncertain about catheter position, epidural test dose was abandoned but the catheter was secured in place.
As per original plan, SAB was done in L34 ISS with 25G Quincke needle without experiencing any technical difficulty. 3 ml of 0.5% hyperbaric bupivacaine was given after free flow of CSF to aspiration.
Patient during  positioning on the fracture table was pain free but patient complained of pain to incision.
Epidural catheter reaspiration showed CSF. Hence hyperbaric 5% lignocaine was injected into the catheter to try and attempt a continuous spinal. 0.5 ml produced no improvement in analgesia or no decrease in BP. Every 5 mins a dose of 0.5ml ( total 3 doses)  was repeated but did not produce any effect.
Then 2% lignocaine with 1 in 200000 adrenaline was injected into the epidural catheter 2 ml / every 10 mins. After injection of about 6 ml, analgesia was complete and adequate and from then on surgery proceeded uneventfully. Intraoperatively 2 other epidural  top ups of 4 ml each were used without any untoward effect on block characteristics or hemodynamics.
1.   How better could this case have been managed
2.   What is the management protocol  followed by majority in event of dural tap and / or CSF in the catheter
3.   Why did the spinal become patchy.  Although the most likely cause is placement of drug in the wrong space ( partially atleast because there was a block) Just wondering that if the lingo injected in L34 could have  spilled out of the subarachnoid space along with CSF from the dural puncture in the L23 space. Is that a possibility. Has anybody experienced it
4.   CSF in the catheter – was it from the catheter being in the subarachnoid space or the CSF leaked out of the dural puncture site and lying in epidural space. How to differentiate between the two scenarios.
General Discussion / AHA /ECC 2010 Guidelines - ETCO2
February 04, 2011, 01:35:52 PM
AHA/ ECC 2010 guidelines on CPR
under ACLS
Confirming ETT placement - Class I recommendation ( Level of Evidence A)
For monitoring effectiveness of CPR - Class IIa
FOr monitoring return of ROSC - Class IIa
For monitoring post cardiac arrest intensive care - Class IIb

How many of you on this forum beleive that we can comply with this recommendation
How many of us use ETCO2 for all GA cases as is recommended in minimum mandatory monitoring protocol
In fact how many of us use it for high risk surgeries like Laprascopic surgery and pts with COPD

If we cannot follow a Class I recommendation are we liable to negligence
This is of great importance what with medical tourism increasing in our country and we have to anaesthetize more  and more of foreign nationals

Would like to hear your thoughts


A 70 year old man with fracture Neck of Femur is scheduled for surgery

If the patient was on Aspirin 75 mg OD

1. Would you postpone the surgery
2. If no, why
3. If yes by how many days and why

If the patient is on Clopidogrel 75 mg OD

1. Would you postpone the surgery
2. If no, why
3. If yes by how many days and why

Remember that prolonged immobilization comes with its own set of problems

#8 News / Spam on this site
August 28, 2010, 02:55:07 PM
Dear gasman
or who so ever is so diligently moderating this site
Looks like trouble out there
site is being bombarded by unsolicited spam
I wonder if this is going to screw up our comps
so who ever is incharge can this be taken care of
thanks in advance
General Discussion / Unexplained Tachycardia
March 02, 2010, 12:25:16 PM
26 year old healthy adult presents for hernioraphy. History is normal, claims to be a slightly anxious personality and occasional palpitation when stressed. Effort tolerance is greater than 8 METS.
Clinical examination reveals no other problem except a resting heart rate of 145 bpm. Examined on several occasions and found to be consistently above 140 bpm
patient has  normal CVS finding, ECG shows narrow complexed tachycardia, Xray is normal. All biochem including Thyroid function is within normal limits.
ECHO shows normal study exxcept for the tachycardia noticed during study.
Patient was initially started on Alprazolam 0.5 mg HS.
No improvement lead to additon of Tab. Propronalol 20 mg intitally OD and subsequently BD.
Propronalol, and not cardioselective beat blocker choosen for the complimentary CNS anti-stress effect of the drug
After 1 week rates continue to fluctutate between 130 and 140 bpm.

Do we proceed with this rate. or do we further need to stabilize his rate,

a 22 year old woman is posted for encirclage for cervial incompetence. Procedure is likely to last 10 to 15 minutes only

She is a known case of Mitral stenosis of Rheumatic etiology
Her effort tolerance is 4 METS
she has a history of Dyspnoea on Exertion NYHA class 2
Her last Echo shows a MVO size of 1 cm2. She has mild PHT and her LV function is good
She is in sinus rhythm and on regular anti- CCF therapy

our plan
Debated about short duration day care procedure and role of Spinal anesthesia
Also debated about potential for full stomach scenario and aspiration risk
Wondered about the utility of blocks like pudendal and paracervical and dropped them due to lack of experience and confidence
IV ranitidine and IV MEtoclopramide 10 mg given 30 min before surgery
Routine monitors including ETCO2 and IV line started. Fetal heart rate monitoring started
Patient received Glycopyrrolate 0.2 mg + Fentanyl 2 mcg /kg
SC Terbutaline was used as tocolytic as only that was available
Induced with Propofol 2.5 mg / kg mixed with Lignocaine 1 mg /kg
Once under, size 3 PLMA inserted Positioning confirmed
N2o + O2 + Isoflurane intial IPPV followed by Spontaneous assisted ventilation
Ryle's tube inserted
Procedure in lithotomy lasted 17 minutes
Recovered in supine and extubated fully awake

Is this technique good enough or are there any holes to punch into it
Was it OK to overcome our intial urge to be safe and just go with a spinal since we hoped to return patient home as early as possible

Thanks for your inputs
At the beginning let me confess that although recommended we seldom seem to follow the MODIFIED ALLEN'S TEST before we start A-lines on radial arteries of patient

Now the case scenario

A 32 year old lady was taken over by us in the surgical ICU after a major laprotomy for catecholamine secreting tumour. Her pre-operative co-morbities included hypertension, LVH and severe anaemia. All of them were corrected to optimal levels
Anaesthesia consisted of GA/ CV supplemented by a thoracic epidural. Intra-operatively she had her IJV cannulated but was maintained on ANIBP for lack of transducing facilities.
Intra-op problems included need for vasodilators initially and later vasopressors/ inotropes including Noradrenaline and Dopamine. She also received massive blood transfusion to replace her loss
Post-operatively she was put on elective ventilation.
Day 2 when we took her over, she had signs of septicaemia, myocardial dysfunction and a host of multisystem problems and was still on the ventilator.

All standard treatment protocols were inititated and to permit repeated ABG analysis and also to monitor CO and other variables including Systolic Pressure Variation, it was decided to put the patient on VIGLEO the PICCO monitor of Edward Lifesciences.
As per requirement, her left Radial artery was cannulated using a 18G cannula using the regular tranfixation technique. ALLENS TEST NOT DONE. Procedure was uneventful and tracings on the A-line were good.

24 hours later patient's left hand distal to the A-line became discoloured, cold and clammy. A diagnosis of vascular insufficiency was made. Causes seem to be multiple, but definitely also included suspected insufficiency of the palmar arch, which was not tested..
A-line was removed. Vascular opinion confirmed vascular insufficiency and patient was put on Heparin

We eventually lost the patient to MOFS,  but the blood flow to the affected limb did not improve.

A large number of papers are available that question the specificity and sensitivity of MODIFIED ALLEN"S TEST. All our Cardiothoracic surgery patients also do not have this test prior to their arterial cannulation
So do we need to perform it mandatorily

Although I did search I never found this out
What is the difference between ALLEN'S TEST and MODIFIED ALLEN'S TEST

Should this test be done only for arterial cannulation or also before we prick the artery for taking an ABG sample
Would leaving out this test and ending up with a very rare complication like this amount to negligence

Keenly looking forward to your inputs and experiences


Presenting a case report and hoping to arrive at some answers from your knowledgeable inputs.

35 year old lady posted for laprotomy for growth ascending colon.
No significant past history or co-morbid illness.
Effort Tolerance > 4 mets (can climb 3 floors without any dyspnoea)
No allergy / drug intake

examination was all normal including resp system
Cxr was normal
Breath holding test > 25 secs
Assessed as ASA 2 due to malignancy and increased risk of peri-op DVT and Type C surgery requirements

In OT got all standard things done
Patient received a thoracic epidural to site the catheter tip at T9 for post-op analgesia.
Patient then received a GA consisting of Fentanyl 2 mcg/kg + Lignocaine 1.5 mg/kg + Thiopentone 5 mg/kg + Vecuronium 0.1 mg/kg
Ventilated for 3 mins
Laryngoscopy showed a class 2 Cormack Lehane but the laryngeal aditus appeared narrow
7mm ETT tried could not be passed
6.5 attempted - still not passing
Patient larynx finally accepted a 6 mm ETT

Connected to machine and IPPV started.
Bag a little tight
Auscultation showed ? wheeze
All anti-bronchospasm interventions undertaken
Meanwhile patient starting to desaturate and there is decreased airentry on right side
Diagnosis of Pneumothorax suspected.
Needle thoracostomy reveals air in pleural space
ICD inserted and surgery proceeds without any further event.

I saw this case post-operatively in the ICu with the ETT insitu and working ICD
24 hours later lung not re-expanded.
We continue checking ICD and Nebulized brochodilators  for another day
48 hours later - lung still collpased

We did a FOB and found right bronchus blocked with secretions.
We did a thorough suction
12 hours later CXR showed good expansion
24 hours later repeated FOB inspection and suction.
successful extubation was acheived later.

1. How did a normal lung develop pneumothorax? Where did we go wrong? Remember CXR - no bullae and resp reserve excellent
2. Did the secretions and intraluminal obstruction contribute to the pneumothorax in any way
3. Any better way of dealing with this case.
General Discussion / Intra-operative Anaphylactic Reaction
September 16, 2008, 01:37:25 PM
I find that a lot of Anaesthesia residents quoting use of IM adrenaline for intra-op Anaphylaxis when there is a good IV line in existence. In my opinion intra-op we should prefer the IV than any other route for administration of drugs because the absorption of the drugs can never be assured by any other route
Would just like to know what the general opinion is

Ask an Expert - Case Studies / Iatrogenic CVCI
February 20, 2008, 05:05:06 PM
65 year old male had Ca oesophagus middle 3rd. Underwent a thoracotomy - Oesophageal dissection - mobilization of stomach through the mediastinum and anastomosis in the neck.
Airway was Cormack class 2a and intra-op was uneventful
received 24 hours of post-op ventilation and on day 2 was sequentially stepped down and put on T piece SBT. He had copious lung secretions and was on appropriate nebulized and IV therapy
I am on call and we are waiting for ABG results before we extubate him. He has a bout of severe cough and totally obstructs his ETT with all features of upper airway obstruction. Suction catheter will not pass.
Since I was waiting to extubate anyway, I removed the ETT. I choose not extubate over GEB for fear of pushing the mucus plug into the bronchus and the attendant problems.
Post extubation, patient is unable to breath. IPPV attempted with Ambu bag but no air moving into lungs
Emergent re-intubation planned - laryngoscopy - no sturcture can be identified - just edema everywhere and everything looks like a bunch of grapes.
2 Blind attempts at intubating with GEB got us only into the esophagus
Still cannot ventilate at all and meanwhile patient dropping saturation very fast into low 50's

CVCI scenario - ? induced by me
Had a few helping hands around. 2 persons continue to attempt mask ventilation. I opened the cricothyroid membrane (Emergent surgical airway)  with a 11 blade. Antr jugular vein bleed managed with compression with pad.
smallest ETT available at hand is 6.5 mm.
Difficult to get it into trachea. Used a large straight artery forceps to hold the opeing wide while someone passed the ETT. Ambu ventilation commenced with 100% O2. Sats and consciousness improved
Got urgent ENT consult and got a regular tracheostomy done and cricothyrotomy wound sutured closed

Patient is doing absolutely fine. Thankfully we managed to avoid complications of hypoxia
1 week after the incident arranged for a videa-laryngoscopic examination. Severe edema still persists. ENT people stopped at the epiglottis edema itself and did not want to proceed further

Can the gastric acid from the stomach in the neck be responsible for this edema

By the way this is only the 2nd cricothyrotomy i have attempted in my entire career. In the first instance i failed to save the patient

1. Even if there is ETT obstruction extubate over GEB
2. Cricothyrotomy can be life saving
3. In real life rapidly deteriorating situation, cricothyrotomy is difficult to perform. Theory makes it sound simple. So please attend regular airway workshops to hone up your skills

COULD things have been done more safely ?
This is a common case scenario for all of us
Elective surgery with abnormal Thyroid function test
We are trying to evolve acceptable guidelines that we can enforce on our surgeons but they need to be reasonable and scientifically backed too
Would like to place 3 scenarios and also give my take on it

Hyperthyroid MNG coming for total thyroidectomy.
Treated for last 2 weeks with Carbamizole and Propronolol.
Last TFT
T3 -↑
T4 - ↑
TSH - ↓
Surgeon wants to proceed with surgery without waiting for biochemical correction

Treat for 3 – 6 weeks
Look for improvement in clinical signs like weight gain, less hunger and Sleeping pulse rate < 80bpm. Forget tremors
Forget absolute biochemical correction.
Look for 2 TFT showing trend towards improvement.
Accept at increased risk for adverse peri-operative cardiorespiratory event

Hypothyroid coming for thyroidectomy
On thyroxine
Last TFT
T3 -↓
T4 - ↓
TSH - ↑
Surgeon wants to proceed with surgery without waiting for biochemical correction

Treat for 4 -6 weeks
Carefully evaluate for IHD
Forget absolute biochemical correction.
Look for 2 TFT showing trend towards improvement.
Accept at increased risk for adverse peri-operative cardiorespiratory event

Hypo(more common) or Hyperthyroid coming for quasi emergency surgery like Upper humerus fixation or Lumbar disc disease with compression for laminectomy
Just detected
Treatment just started
No time to wait for 2 -3 weeks
Start on appropriate treatment atleast 3 to 7 days
Look for Free T3 and Free T4 index and hopefully if they are OK proceed with surgery even if the rest of the TFT is abnormal


In private practice I end up tackling all aspects of anaesthetic care with little untrained help if any. I guess a lot of you are also doing much the same
I find extubation of children who have had tonsillectomies far from perfect and intimidating, requiring a lot of physical restraint of the kid. I have tried various strategies. But the results have been largely inconsistent and far from utopia.
So I am hoping to be educated by people who may have mastered the technique
Adults are easy to handle. But kids between ages 3 to 15 pose whole lot of emergence problems. Paediatric practice constitutes less than 15% of my total anaesthetic practice

Fasting for 6 hours
Premedication – Inj. Tramadol 0.5 mg/kg + Inj. Glycopyrollate 0.1 mg/kg IM 1 hour before surgery
In OT-  20 or 22G IV cannula. No fluids hooked on.
Monitors – 3 lead ECG, ANIBP, SpO2, ETCO2 and precordial stethescope
Preoxygenation – 100% O2 X 3 mins
Induction – Fentanyl 2 mcg/kg + Xylocard 1 mg/Kg + Propofol 3mg/kg + Rocuronium 0.6 mg/kg
Ventilate with 100% O2 and 2% Sevoflurane
Intubate at 90 secs – appropriate size RAE preformed oral ETT, confirm BAE,  fix
Maintenance – 70% N2O + 30% O2 + 2% Sevo - IPPV with Mapleson F or Circle system with anaesthesia ventilator
Titrate ventilation to ETCO2 around 30 – 35 mm Hg
Intra-op drugs include Ondansetron 4 mg, Antibiotic IV and Sometimes Decadron if airway edema suspected.
Relaxant and Narcotic top up usually not given, used only if needed.
Procedure( Laser assisted adenotonsillectomies) usually lasts 60 to 90 mins.

End of procedure – Cut sevo to 0.5%. Hand ventilate with high flows. Suction and final inspection of airway done by surgeon
Demonstrate physical recovery of diaphraghmatic function.
Reverse with Neostigmine 50mcg/kg + Glycopyrollate 10mcg/kg. Switch to 100% O2 and don't stimulate patient again until he is ready to extubate.

Awake comfortable patient
Opens eyes to commands
Airway reflexes are fully recovered
Hopefully TOF > 0.9
Adequate respiratory function and haemodynamics

Adults  > 90%
Children < 20%

Kids wake up struggling, require severe restraint. Extubation is not smooth. They are crying and agitated and don't make a pretty picture. Since it is an airway surgery prone to airway problems, I prefer to do an awake intubation

Extubate child while still breathing 0.5% Sevo in 100% O2 – deep extubation – Increased my incidences of post-extubation breath holding and laryngospasm

Deep extubation with N2O on flow – still post- extubation airway Problems

IV Xylocard – works brilliantly in adults but not so in children

Dribble in 2% Lignocaine into ETT or spray 10% lingocaine down the ETT about 3 - 5 mins before extubation, hoping they will tolerate ETT better. Not good enough


Regional Anesthesia / Epidural and unfractionated heparin
December 02, 2007, 05:06:00 PM
40 year old peripheral vascular disease patient was posted for femoro-popliteal bypass.
anaesthetic plan was
sequential combined spinal epidural - 2 needle, 2 interspace technique
Epidural was performed in L3L4 ISS and catheter was placed cephalad - 6 cms.
Epidural vein was cannulated - free flow of blood in catheter
Catheter withdrawn each centimeter and negative aspiration performed
At 4 cms into space no free flow of blood seen
Test dose given - No rise in HR seen -  catheter assumed to be in epidural space
SUCCESSFUL but TRAUMATIC epidural catheter placement acheived
SAB done in L4L5 ISS with 3.5 ml of hyperbaric bupivacaine
Surgery started
2 hours into surgery, as is routine in vascular cases, surgeon wants 5000 IU unfractionated heparin. Additional repeated doses may be needed

ASRA recommendations advice avoiding anticoagulants after traumatic epidural  for 24 hours if possible or weighing of risk - benefit ratio in such a scenario.
Would like to hear opinion of people who have been stuck in similar conflicting scenario

General Discussion / CVP - which scale
October 31, 2007, 04:55:41 PM
Which scale are people following to maintain CVP
mm of Hg
cm of H2O

Why did i get this doubt?
In CVP guided fluid resuscitation there exists a rule
"5-2" rule if you are using CVP
"7 -3" rule if you are using PCWP.

Now in 2 CME's I find that authors have used different units. One has opted for mm of Hg and the other the latter

It is very important to know because a CVP of 5 cm of H2O = CVP of only 2 mm of Hg.
Using the wrong scale may definitely be misleading
General Discussion / Cannot ventilate ?
October 13, 2007, 10:22:43 AM
While performing a ET intubation for a GA as per scientific recommendation, i follow pre-oxygenation and demonstration of adequate mask fit and ventilation after inducing anaesthesia prior to administration of relaxants.
So here is an scenario that is not uncommonly encountered
50 kg, ASA 1, Modified Mallampati Score 1, No other positive predictors of difficult airway or difficult mask ventialtion, No aspiration risk, scheduled for GA / CV.
IV line, monitors
Fentanyl 100mcg + Glyco 0.2 mg + Xylocard 50 mg + Thiopentone 250 mg

Mask ventilation failed
Jaw thrust and 2 person mask ventilation failed
Appropriate oropharyngeal airway in place  - mask ventilation failed

Saturation are holding due to adequate pre-oxygenation
time elapsed 3 mins

What should one do next. Give suxa as planned or do a laryngoscopy and intubate minus relaxants, try ventilation with LMA

thanks for all the input
General Discussion / Anaes vs. Surgeons - happy reading
September 11, 2007, 11:55:54 AM
by Malcolm Fisher (World Medicine October 1976)

Surgeons and anaesthetist have a curious sadomasochistic relationship.
Roland and Oliver, Laurel and Hardy, Tristan and Isolde, Lillee and
Thompson have been dissected, analysed and lauded. The equally
temptuous relationship between surgeon and anaesthetist is less
lauded, and sometimes less laudable.

The love-hate aspects of the relationship are governed by two
historical truths: without surgeons, anaesthetists would be unemployed
(hence the diversification into intensive care, pain clinics,
hyperalimentation, and the like), and, because all surgical progress
has been made possible by anaesthesia, without anaesthetists, most
patients would rather keep their gallbladders, prepuces, and ugly noses.

As surgery has progressed and become more horrendous the function of
the anaesthetist has changed from providing good operating conditions
for the surgeon to saving the patient from the surgeon. As one cynic
put it: "They will do brain transplant one day, just as soon as I can
work out which bit to wake up".

I got my first insight into this unique relationship when I changed
from being a surgical resident to being an anaesthetic resident. On my
first day I learned the basics from someone who, while unknown in
scientific circles, is regarded highly in the antipodes as an
anaesthetic philosopher. In my first five minutes he taught me the
three fundamentals of anaesthesia.

* "Always check the oxygen supply."
* "Always identify the patient and the operation."
* "Hate all surgeons and hate the slow bastards most."

I was a little taken aback but I soon learnt that these rules, like
many other things he told me, were essential for survival. On my
second day, he initiated me into the inner circle which knows the
Cook's three laws of surgery:

* Surgery begets surgery.
* The adjustment of an operating light is an immediate signal for
the surgeon to place his head at the focal point.
* No substance is more opaque than a surgeon's head.

After three weeks I believed I had anaesthesia mastered, much so that
I asked a surgeon what the difference was between a three week
resident anaesthetic and a twenty year consultant anaesthetic.

"Very little," he informed me brutally. "the only major difference is
that when something goes wrong and a junior is anaesthetising, I know,
and when a consultant is anaesthetising I find out in the tea room
when it is all over."

I confronted the anaesthetic philosopher with this disturbing
information and learnt the next most important lesson.

* "Never tell the surgeon anything. There is nothing he can do and
he will only get in a flap."
* There were only four things he said to tell surgeon in time of
* "Please get the retractor off the heart."
* "Could you stop a few bleeders and give me time to catch up."
* "Could you give cardiac massage."
* "You can stop now – he's dead."

I then went on and learned the complexities of the
surgeon-anaesthetist relationship. I heard of the famous Jones
technique of anaesthesia where the anaesthetist stands at the foot of
the table and tells the surgeon how to operate while the surgeon's
assistant hold the patient on the table. I learned that fitness for
anaesthesia was a meaningless term; anyone who could lie down was fit,
but fitness for surgery was a different matter entirely.

Fitness for surgery can be decided over the telephone by asking who
the surgeon is, where the patient is going after, and what the
operation is. All the pre-operative examination tells you is how and when.

I learned to understand the prima donna complexities of the surgeon
and to recognise when the operation was not going well.

* All surgeons follow the same procedure.
* Adjust retractors
* Reposition assistants
* Make bigger hole
* Change sides
* Order multiple light adjustments
* Ask for more relaxation
* Curse scrub nurse, resident, registrar, health commission,
government, anaesthetist, and deity
* Remove alternative organ and close.

Over a few further years I learned the two other important things that
every anaesthetist must know.
Surgical textbooks always list causes of excessive bleeding during
They include incompatible blood transfusion, massive transfusion, poor
position, halothane, ether, patient too light, patient too deep,
hypoxia, hypercarbia, straining, and so on.
They never mention scalpels, tearing vessels or swabbing away clots.

In fact when a surgeon glares " Can you do anything about the
bleeding?" the best reply is "Certainly, but who will mind the patient
while I scrub?"

There is also a list of great surgical lies which every anaesthetist
will recognise.

* "Put him to sleep, I'll be down in five minutes."
* "He is old but he is fit."
* "You will like her, she's and old dear."
* "I haven't cross matched blood, we don't need any."
* "Don't put a tube down, it's just a quick snatch."
* "I'm just going to open, have a look, and close her."
* "She will die if I do nothing."
* "I'll be finished in ten minutes."

Surgeons appreciate a reciprocal number of anaesthetics lies as they
appreciate the law that fitness for surgery is universally
proportional to time of day.

And let surgeons beware when they hear:

* "The blood pressure is 123/72."
* "The patients is maximally relaxed and won't breathe for a week
if I give any more."
* "It's not cyanosis, it's just the bloody lighting."
* "Don't go away, it will be two minute turn around."

The subliminal implication of the lies must be appreciated by both
members of the relationship if they are to function in the best
interest of the patient, and perhaps the greatest advantage of the
lengthening postgraduate courses is to give fledgling surgeons and
anaesthetists time to appreciate the idiosyncrasies of the other.

As another cynic said: " Anaesthesia is the half asleep watching the
half awake being half murdered by the half-witted."
Only the other day when my colleague in the next theatre was
complaining bitterly: "What can I do about my mother-in-law?" the
surgeon withdrew his head from the thorax and snapped: " Why not give
her one of your anaesthetics?"