Conference Lectures
When to Refer the patient to a specialists by the Anaesthesiologist?
Dr.M.Kannan
Professor Emeritus Tamilnadu MGR Medical University
National Governing Council member of ISA
The primary aim of all anaesthesiologist is to achieve optimal anaesthetic condition for surgery. In that process mortality and morbidityis unacceptable by anyone.Therefore an excellent perioperative care is obligatory. Risk analysis and optimisation of the chronic illness are fewfundamentals in the perioperative care. Scientific advancement has revolutionarised the diagnostic tools and medical management. Some of the situation is highly complex so that a collective wisdom is mandatory to improve the surgical outcome.
Depending upon the complexity of the surgery and co morbid condition of the patient the strength of the team varies. Apart from medical personals,the paramedical personals, technicians and the hospital administrators also plays an important role in the team. We by our training and experience can easily asses the skill ,knowledge level and commitment of the team members, which greatly influences the surgical out come.The proverb “The strength of the chain is the weakest link of the chain” is not out of contest at this juncture.So we cannot be a silent spectator when we spot out a weak link. We should freely communicate with surgeons and other medical consultants and should not hesitate to record his opinion and clear our doubts on the better interest of the patient. Since we are thePeri operative Physicianswe(Anaesthesiologist) should be well versed with common medical illness and therapeutic regimen.
A too polite attitude to accept all instructions and directions from medical consultant is absurd. An average anaesthesiologist is well trained in managing acute medical emergencyin the periopertive period. But an average medical consultant will not be in a position to predict acute medical problems during the perioperative period in a patient of chronic illness since such situationsare not in his regular work schedule. Therefore his instruction (eg:give light anaesthesia, maintain high FIO2) or direction (eg: avoid hypertension and hypoxia) are meaningless. Unfortunately if any anaesthesiologist follow such instruction and in the event of mortality or morbidity in the perioperative period, will lead to an unnecessary controversy and then to a legal battle.
A stubborn attitude of not to consult anybody is dangerous to the patient as well as to the anaesthesiologist himself.As expressed above the modernisation in diagnosis and therapy is so rapid that most of the anaesthesiologist require many useful information, specific data and final conclusion about the patient before he makes a risk analysis with respect to the planned surgery. A medical specialist consultation is obligatory to optimise the function of an unhealthyorgan system and the time expected to optimise it. Similarly first hand knowledge regarding the coronary stents and the pacemaker and information regarding the patient dependence on them can be obtained from the attending physician only. Rare diseases and its present day managementmany a time, we have to obtain from concerned specialist. So a healthy nexus with medical specialist is alwaysnecessary.
The choice of middle pathway is not easy. First it requires detailedpreoperative examination and access to all his medical records and if necessary anaesthesiologist is empowered to order for more investigations.Pre operative assessment is mandatory protocol in all teaching institutes and corporate hospitals but it is conveniently bypassed frequently by all the doctors including the anaesthesiologist, the reason very well known to them only!Therefore I feel it requires tremendous will power to implement the same.
Second step is to make a clinical diagnosis of the medical and surgical disease and the risk assessment. If there isa difficulty in making the diagnosis or assessing the extent of damage of various systems which bear anaesthetic and surgical implication one has to resort to specialist consultation.
Third step will be optimisation of chronic illness. This will be done by concerned specialist and a consensus should be arrived regarding optimisation and alteration of drug therapy during perioperative period.
Fourth step will be handing over the patient to the medical specialist for continuing medical management at the end of perioperative period.
Fearing the difficulties in the above steps many of us resort not torefer to anydoctors or fitness demanding (from Physicians) Anaethesiologist !
If middle pathway is not favoured in your work place, you have to make a social change slowly. If you happen to practice in a group or in an organised department first a consensus has to be arrived and a protocol to be formed among your self.( lone practitioner can also form a protocol for himself and adhere to it). Secondly personnel communication with consultant about the patient medical condition should be a routine. Put forward simple thought provoking questions.(eg- what form beta blocker to be continued after gastrectomy when continuous ryle`s tube drainage is contemplated?)Do not ignore theinvitations of theiracademic meetings and your judicious participationsis mandatory to establish your status.Do not forget to invite them for your programmes.Thirdly constant update is mandatory other wise you will become a laughing piece.
At the end of the this exercise the anaesthesiologist should be achieve the followingfrom the medical consultant as a routine
- Diagnosis if you could not make
- Extent of target organ damage
- Optimisation of the patient
- Provide data of patient which helps in effective perioperative management
- Correct contact information, including an emergency phone number and willing to participate in patient care any time on request.
In course of time consultant medical specialist will understand that the anaesthesiologist are betterperiopertive physicians to manage acute medical problems in the perioperative period and what they do not need are“Clearance”, “fitness”,Absolute recommendation such as “Avoid hypoxia -/hypotension” and ASA-riskassesment.
Once implemented it will reduce the incidence of“on the day” cancelation of surgeries and also mortality and morbidity. Anaesthesiologist will feel the fulfilment of his job which will keep him going for long years.