SAYING “NO” WHEN IT IS

IMPORTANT

DR.S.N.KRISHNAMOORTHYM.D., D.A., D.N.B., B.G.L., P.G.D.M.L.E.,

SAYING “NO”

• Medical profession is a noble profession wedded to service and sacrifice.

• Its services are available to all regardless of extraneous considerations.

Saying “No”

• Denial of anaesthesia services is justified if actuated by noble and laudable objectives of averting anaesthesia related complications which are anticipated

SAYING “NO” IN ANAESTHESIOLOGY

• The decision to say “No” is based on the clinical facts and circumstances of the case.

WHY THE OCCASIONAL NEGATIVE APPROACH?

1. Anaesthesiologist always works as part of a team.

– Deficiencies of other team members impinges on anaesthetic management and enhances risks and complications.

• The Operation Theatre is always in the control or possession of the surgeon.

• Surgical needs are very well taken care of .

• Anaesthesia requirements may suffer neglect.

• Minor deficiencies in the anaesthesia set up have the potential to cause serious complications.

WHY THE OCCASIONAL NEGATIVE APPROACH?

• In the event of intra-operative mishaps, anaesthetist finds himself in a very weak position.

• Often, dishonestly drawn into the medico-legal muddle.

WHY THE OCCASIONAL NEGATIVE APPROACH?

• No opportunity to develop rapport with the patient

• Mostly unknown to patients, a thankless job – though crucial and life-saving.

WHY THE OCCASIONAL NEGATIVE APPROACH?

SAYING “NO”

CLINICAL SITUATIONS>>

ANAESTHESIA WITHOUT PRE-ANAESTHETIC EXAMINATION OF PATIENT / AIRWAY

• Common clinical situation in emergency surgery especially obstetrics.

• Unexpected clinical/technical problems

Lack of preparedness leads to disaster.• Even in the worst emergency, pre-anaesthetic

evaluation is a must.

GA IN A PAEDIATRIC PATIENT WITH ACUTE RESPIRATORY INFECTION

• Acutely inflamed respiratory passages.

• Instrumentation leads to high incidence of bronchospasm / laryngospasm.

• Completely avoidable.

GA IN ACUTE RESPIRATORY INFECTION

• IT IS ON THE PATENCY OF THE BRONCHIOLAR

LUMEN AND QUIESCENE OF RESPIRATORY

REFLEXES THAT SMOOTH GENERAL ANAESTHESIA

DEPENDS - NOSWORTHY

PATIENT “UNFIT” FOR ANAESTHESIA

• Multiple severe & uncorrected physiological derangements and multi-system disorders.

• Co-existing Anaesthetic problems

• Meddlesome anaesthesia

Patient unfit for anaesthesia

• Anaesthesia is a double-edged sword; capable of conferring great benefits to mankind if applied properly.

• It can also do great harm if applied by or to the wrong person

Denial of anaesthesia services

• Chloroform has done a lot of mischief; it has enabled every fool to become a surgeon – George Bernard Shaw in “Doctor’s dilemma”.

ANAESTHESIA FOR PARTIAL RESPIRATORY OBSTRUCTION

• Patients are restless and un-cooperative

• Anaesthesiologist is called upon to ‘sedate’ or ‘quieten’ the patient for the procedure.

• Administration of CNS depressants/muscle relaxants is dangerous

DIFFICULT AIRWAY SITUATION WITHOUT AIRWAY GADGETS

• Many airway gadgets are available today

• Blind techniques with false hopes of successful intubation is unacceptable.

• Airway management is the exclusive responsibility of anaesthetist.

LACK OF BASIC MONITORS/INVESTIGATION

• Deficiencies in the anaesthesia setup should not be condoned but corrected.

• Alternatively, their implications should be discussed and consent secured.

• Safety of anaesthesia is paramount.

WHAT IF YOU DO NOT SAY NO?

• Dr.Minaxiben V. Aruna Kothari, Ahmedabad.[Gujarat State Consumer Disputes Redressal Commission, Ahmedabad; complaint No; 77 of 1993. decided on 6/8/1996.

• Known cardiac patient with unstable cardiac rhythm given general anaesthesia for an orthopaedic surgery in the right upper limb.

• Patient developed ventricular fibrillation; could not be resuscitated for want of defibrillator in the O.T.

WHAT IF YOU DID NOT SAY “NO”

GUJARAT STATE CONSUMER COMMISSION

• “She should have procured the same as a precaution before starting anaesthesia OR

• could have refused to give anaesthesia without the said machine OR

• she should have brought these facts to the notice of patient’s relative which unfortunately she did not

“CRIMINAL NEGLIGENCE”

*Indifference to an obvious risk

**Actual foresight of the risk with determination nevertheless to run it

***Appreciation of the risk with attempted avoidance weak

****Inattention to a serious risk which goes beyond ordinary negligence

CONCLUSIONS

• “LURE OF THE LUCRE” should not lead us astray.

• Anaesthesia practice should at all times be patient-centric; it should NEVER be surgeon-centric.

• Say “No” to all avoidable risks.

• Safety of anaesthesia is supreme and paramount.

THANK YOU!