Thursday, January 28, 2010
The Zen of Anesthesia
I was giving a MAC anesthesia to a patient in a sitting position for a brain biopsy. The head is completely draped and inaccessible. It is also pinned to a metal frame fixed to the OR table by a Mayfield device so an emergency laryngoscopy would have been virtually impossible. The case went very well. At the end of the case the surgeon looks at me and says, "It must be nice to get paid for just sitting there and doing hardly anything."
I was shocked he made this statement. I replied, "I only make it look easy." Internally I was indignant. I would never deign to presume that his work is simple and mechanical. Somehow he felt it was appropriate to make that remark to me. What he doesn't see is all the internal calculations that are a constant when a patient is under anesthesia. Is the patient's cerebral perfusion pressure adequate? What precautions have I made in case the patient gets an air embolus. Is the anesthesia deep enough to make sure the patient doesn't move while his head is pinned to the table? Is it light enough so that the patient can maintain a patent airway? If the anesthesia is too deep and he obstructs should I put in an oral airway? What if he starts coughing when an airway is put into his mouth? The patient has coronary artery disease and has had a cardiac bypass. Are his coronary arteries being perfused adequately? Are his blood pressure and heart rate optimal? He's rebreathing some CO2 under the drapes. How is that going to affect his pulmonary artery resistence pressure? How does his ETCO2 waveform look? Do the diminished waveforms mean the patient is obstructing or has the sample line moved? Are the patient's extremities adequately padded? Are his eyes protected from corneal abrasions?
All these questions and more go on inside my head throughout the procedure. But on the outside I exude the calm and confidence of a professional with years of experience in the OR. Thus the surgeon leaps to the conclusion that the anesthesia was "easy." I frequently tell surgeons that they want to see relaxed anesthesiologists. If they see their anesthesiologist running around at the head of the OR table, frequently ducking under the surgical drapes, and otherwise working frantically, then you know your patient is in trouble. So don't make the assumption that because your anesthesiologist is sitting there that the anesthesia is undemanding. It just means your anesthesiologist is in complete control of the patient's situation and you have nothing to worry about and can conduct your procedure with confidence. While you surgeons perform your single-minded task at hand, know that the other physician in the OR is watching out for the patient to make sure the operation is a success.