Saturday, September 15, 2007

will anaesthetists please make up their minds about 'it'!!

i guess everyone undergoing a specialist's training in anaesthesia has to go through 'it', but i'm about ready to throw a tantrum right now because of 'it'.
and i do mean a real, no-nonsense, fists-and-toes-banging-on-the-floor-and-bawling-away kind of tantrum because 'it' irritates me no end.
'it', my current bugbear, is 'how to do things' in the practise of anaesthesia.
here's how things work. a junior anaesthetist and a senior anaesthetist are posted in a theatre for one whole working day, and provide anaesthesia for all cases coming to that theatre on that day. so the junior has to basically do what the senior wants him or her to. obviously, one allows for the fancies and peculiarities of individuals; i always thought of it as "when in rome...."
but sometimes, it gets to be too much.
here's a few examples:

most people think 100 micrograms of fentanyl should be diluted in a 10 cc syringe for various reasons including being able to titrate the dose, and that giving 100 mcg together can lead to chest wall rigidity. and i guess if everyone does it, it leads to less confusion. but there is a guy who says it's a waste of a 10 cc syringe, and that he's never seen chest wall rigidity, and that most adults can take 100 mcg without any problems. so he uses a 2 cc syringe. that is all very well but for the fact that the same guy insists on using a 10 cc syringe for morphine. when i asked him why not 2 cc, the answer was not very clear-cut. so i guess even people who attempt to sound logical are doing stuff more out of habit than anything else.

i've always been taught here that if one uses a regional anaesthetic technique (like a caudal or epidural or brachial plexus block) in additional to general anaesthesia, one can do without morphine, and thus avoid it's problems. in general, isn't it better to interfere minimally with the body? but there is a person here who absolutely loves morphine and insists on giving it even in patients getting additional regional anaesthesia. the apparent reason is that the patient has pain in the mouth and throat from the endotracheal tube or laryngeal mask which needs to be treated with morphine. fine, the person concerned is an expert on pain management and i'm not about to say he or she is wrong, but surely there is no need to get angry because i did not give morphine till you told me to. i mean, was i supposed to divine that you like to do other than what i had been told to do till then by everyone else?

how does it matter whether i take air or saline or saline-with-a-bubble-of-air in the syringe while finding the epidural space by loss-of-resistance technique? then why insist that it has to be done in any particular way? interestingly, one day, before putting in the needle, i asked one senior what he wanted me to use, and this guy happened to not like that at all! " what do YOU like to use? go ahead and use it!" is what he said! imagine that! on the one day i decided to ask instead of getting rapped on the knuckles (metaphorically) after starting!

truth is, there are more than a few ways of getting from point a to point b in anaesthesia, and i guess i must walk all of them during the training period before i get enough freedom to choose what i'm comfortable with. but i wish they weren't so dogmatic about sizes of syringes and the like. i think i've decided to be a little less picky about the small print when i get the opportunity.