S Ahanatha PillaiMD DA
Emeritus Professor The Tamil Nadu Dr MGR Medical University
Chennai, Tamil Nadu, India
Former Professor Department of Anesthesiology Madurai Medical College and Government Rajaji Hospital
Madurai, Tamil Nadu, India
ForewordSam C Bose
7Foreword
19Hospitalization
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Surgeons and Anesthesia
First Edition: 2014
9789350908372
Printed at
Dedicated to
Professor Dr T Subramaniam FRCS
Emeritus Professor The Tamil Nadu Dr MGR Medical University Chennai, Tamil Nadu, India
Honorary Clinical Professor of Surgery Madurai Medical College and Government Rajaji Hospital Madurai, Tamil Nadu, India
(1971–1987)
Who is better suited to write the foreword for a well-thought out book for surgeons by an Anesthetist? Certainly, an Anesthetist!
But when a surgeon is asked to study the 236-page book and write the foreword, it is a pleasure and honor. Pleasure, because one is educated even in his eighth decade of life and over six decades of nodding acquaintance with surgery since 1952.
A lesson which I learned is, in the first 10 years learn ‘how’ to do surgery, second 10 years ‘when’ to do surgery, third 10 years ‘when not’ to do surgery (these three were taught by the Jambavans of yesteryears), and finally when ‘stop’ doing surgery!
In conclusion, I congratulate Professor Dr S Ahanatha Pillai for writing this wonderful piece of educative manual throwing open the nuances of high quality anesthesia wizardry for the benefit of future generation of men and women of all specialties including ‘surgeons’!
Sam C Bose MS MCh
Former Professor of Plastic Surgery
Madurai Medical College
Madurai, Tamil Nadu, India
9Preface
This small book is aimed at the young surgeons who would like to know something about anesthesia while developing expertise in their own field.
I am fortunate to be in the field of anesthesiology from the ‘open drop ether era’ to the modern-day anesthesia for about four decades and had the fortune of working with three generations of surgeons specially, some of the great stalwarts in surgery of yesteryears. Hence, I humbly feel fit to write about the subject on the title Surgeons and Anesthesia.
There is a natural question, ‘Why should a surgeon know about anesthesia?’ The answer is very straightforward and simple; surgery and anesthesiology are very intimately related and interdependent fields, and as anesthesiologists and surgeons work in the same team, each one must have some orientation about the other's work so as to give the best possible service to the patient in the teamwork.
I brought out the book Anesthesia for Undergraduate sometime in 1995. Since then, there had been a persistent request from many of my good friends and colleagues belonging to various surgical specialties for a simple and comprehensive book that deals with the basics of anesthesiology and other important aspects related to anesthesia and operating department. I am very grateful to all my esteemed colleagues, for their love to me.
My close association with my dear surgical colleagues was so pleasant and enduring for the past four decades that the idea of this book was deep in the back of my mind all these years. Now it is taking shape.
After a lot of thought and planning, keeping all their requirements in mind, this book has been designed a little differently.
The topics and chapters have been chosen in such a way that it may be useful to the postgraduates in surgery as well as practicing surgeons. Preanesthetic assessment and preparation of the patient which would tell upon the ultimate outcome of surgery has been adequately dealt with. Without going deep into the subject, all the practical aspects are discussed with their clinical relevance. This will certainly help the surgeons to easily spot and identify the anesthesia-related problems in the perioperative period so that remedial steps could be taken without delay; and if necessary, call the anesthetic colleague for help.
Apart from discussing fundamentals of clinical anesthesia, less commonly discussed topics such as surgical team, surgeon-anesthesiologist relations, operation theater discipline, planning an operating department, asepsis, sterilization of equipment, coordination of theater work, postanesthetic care, etc. have been included. The chapter “Vital Organs Function and Anesthesia” has been specially included that precisely deals with the possible alterations in function of vital organs due to anesthesia.10
Spinal anesthesia is being practiced extensively and is associated with significant morbidity and mortality. There are innumerable misconceptions about that technique; and for that reason, it has been dealt with more elaborately.
All of us are aware; there is no substitute for ‘Asepsis’ in surgical practice. But, in the modern era of antibiotics, there is a fear whether the concept of surgical asepsis is slowly taking the back bench. So, it has been dealt with more care.
It is not an attempt to tell anything new, but to discuss the already known things to look at it in a little different angle so as to enjoy the intricate details and to use them for the benefit of the patients.
I am very sure; this small book would make an interesting reading for all my esteemed surgical colleagues.
S Ahanatha Pillai
11Acknowledgments
I am extremely grateful to all my teachers, who always made me realize and feel that teaching is a wonderful experience and inspired me to learn that art.
My loving students, both undergraduates and postgraduates, consistently inspired me to continue teaching for more than four decades. I am grateful to them, for their love to me.
My dear colleagues in various surgical specialties have contributed for my development in many ways. Most of them loved me and encouraged me in every endeavor.
I am deeply indebted to Professor Dr Sam C Bose, former Professor of Plastic Surgery, Madurai Medical College, Madurai, a renowned great teacher and a pioneer in the field of plastic surgery for being kind enough to go through the book, make corrections and give constructive criticisms. This book is adorned by the foreword from him. I consider this as a special privilege and I do not have words to express my profound gratitude to him.
My dear younger colleague, Dr G Saravana Kumar, has gone through the whole script carefully and made corrections and contributions. My love is due to him.
I am very grateful to all those patients, the faces of whom I could not remember who submitted themselves for anesthesia and permitted me to learn anesthesiology for the past four decades and for all that they taught me.
I owe my immense gratitude to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director) and Mr Tarun Duneja (Director-Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for publishing this book in a very presentable form in a short time. My boundless thanks are due to Mr R Jayanandan, Senior commissioning editor of M/s Jaypee Brothers Medical Publishers (P) Ltd, Chennai Branch, for the excellent and prompt coordination work he did with regard to this publication as in my earlier four publications.
17Quotes
‘Eternal vigilance is the price of safety’
‘Primum non nocere’—‘first of all, do no harm’
‘Anesthesia is a science, but practiced as an art.’
‘Relief of pain is purchased always at a price. The price in both morbidity and mortality does not greatly differ whatever the agent or agents used.’
— Ralph Milton Waters
‘The proper dose of any drug is enough.’
‘It is not the drug that is dangerous, but the man who administers it is.’
— Sir Robert Macintosh
‘It is a great mistake to suppose that nature always stands in need of the assistance of art… Nor do I think it below me to acknowledge that, when no manifest indication is pointed out to me what was to be done, I have consulted the safety of my patients, and my own reputation effectually by doing nothing at all.’
— Thomas Sydenham
‘All anesthesiologists, however experienced and however accident-free, should be humble enough to recognize that they may make mistakes at any time. These errors may be in technique, judgment or failure of vigilance.’
— John Alfred Lee
‘No hospital is too small for learning and no doctor is too wise not to be benefited from the experience of others.’
‘It is a common mistake to believe that general anesthesia is dangerous and conduction anesthesia (regional) is safe’.
Hospitalization is a dehumanizing process. Even in the best of circumstances, we move the patient into a strange environment, replace his clothes with formless rage, percuss, palpate, and paw at his frightened frame, and essentially remove his personal identity and individuality. With the exception of planned pregnancy or cosmetic surgery, no one voluntarily commits himself to hospitalization with the anticipation of attending a summer resort. Hospitalization is painful to the psyche as well as to the corpus; it forces the patient to adapt to an unfamiliar role of childlike dependency. Hospitalization is also destructive to the family unit, which must suffer the pain of the loved one as well as emotional and financial loss. Always remember that no patient ever enters a hospital just to receive an anesthetic.
What then can we do as anesthesiologists to make the patient more comfortable? Primarily, we must offer expertise. The patient has the right to expect the summum bonum of anesthetic care. This translates into a personal preoperative visit where the anesthesiologist, acting as a total physician, can evaluate the patient's physiologic and psychologic status and where he/she can remediate, if possible, deviations from normal. The anesthesiologist must employ a rational (i.e. nonautomatic) approach to the choice of premedication and anesthetic drugs and technique, and flawless performance of motor skills with gentleness and kindness.
The anesthesiologist must not take shortcuts in patient care, and must monitor all parameters required to ensure patient safety in that particular situation. And, the anesthesiologist must do all with the awareness that although he/she is totally familiar with the operating room and the stress of the perioperative period; for the average patient, an operation is a unique and frightening experience.
There are two shibboleths to be emblazoned upon the white coat of the anesthesiologist. The first is the motto of the American Society of Anesthesiologists: Vigilance. And, the second is the golden rule: ‘Treat other people as you would like to be treated yourself’.
(The Epilogue from the book “Problem in Anesthesia: a case study approach” by Mark B Ravin, MD)