A Family Doctor's Tale -THE ANESTHETIC DEPARTMENT

THE ANESTHETIC DEPARTMENT
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My next posting was with the Anesthetic Department.
Although the Anesthetic Department is in the Singapore General Hospital, the group of 20 Anesthetic Consultants catered for all the 5 public hospitals in Singapore.

It was only a office with a meeting room for the briefing of the anesthetists and duty roster for the week.
There was an hour for discussion and networking before starting work. 
There was no wards. 
The anesthetist work in the operation theater of the hospital he is assigned to. 
As I was new, I was assigned to a different anesthetist every week.
The Head of the Anesthetic Department was friendly and easy going. 
So were the rest of the Anesthetists. 

As usual there was a shortage of staff. 
So work was from 8am to 8am the next day with 1 day rest followed by work on the 3rd day.(in other words work alternate days).
Here there is no paperwork unlike the working in the ward. 
All the paperwork was done in the operation theater.

My learning journey starts in the Operation theater of the Singapore General hospital with the Head of the Anesthetic department. 
The patient has already being examined the night before to exclude any severe heart or lung disease or drug allergy which may affect his general anesthesia.
Outside the operation theater the patient was again examined to make sure that he is the correct patient and that he was fit for surgery. All dentures must be removed because they post an obstruction to the wind passages.
The patient was also asked whether he has taken any food or fluids at least 6 hours before the operation because of the danger of regurgitation of food or fluid into his windpipe.


Before entering the operation theater, the patient had an intravenous drip inserted into a vein of his hand.


This was in case blood transfusion may be needed during the operation. Besides injection of medicines can be done easily through the drip.


Once inside the operation theater, I was given the honor to give the intravenous thiopentone (25mg/kgm). 
As the patient was asked to count to twenty, the injection was given .By the count of 7-8, the patient was already asleep.
A dose of succinylcholine injected was again given intravenously. 
This was a muscle paralysis drug like curare (used by Amazons Indians to paralyze enemies or animals through their blowpipe).
The muscle paralysis is necessary so that there is no muscle movement during the operation.


A Laryngoscope was inserted into his throat to help the proper insertion of the endotracheal tube ( a tube that leads from the mouth to the inside of the windpipe). 
When done properly, the vocal cords or other parts of the windpipe will not be injured. 
The endotracheal tube is then inflated to keep it in place. 
Then the respiratory tube from the anesthetic trolley is attached to the endotracheal tube for the right mixture of oxygen and nitrous oxide(the infamous laughing gas or anesthetic gas) entered the patient's lung. 
The lungs must be checked to be sure that the gases are entering correctly. 
Once the patient is fully anesthesized, he is handed  to the surgeon to start operating.


During the operation , the patient will have his blood pressure, pulse and respiratory rate checked as well as the level of nitrous oxide and oxygen gases and the flow of the intravenous drip.
If there is any movement during the operation the surgeon will inform the anesthetist who will have to increase the dosage of nitrous oxide to improve the level of muscle paralysis.
Once the operation was over, the patient was handed back to the anesthetist to reverse the anesthesia.


A dose of neostigmine was injected intravenously to reverse the muscle paralysis and the nitrous oxide was stopped with oxygen still being given. 
Once the anesthetist feel that the patient muscle paralysis has passed and he is able to breathe on his own, the endotracheal tube is removed. 


The patient is then pushed outside the operation theater on the bed trolley and usually kept to one side with his face facing down.   
In rare cases there may be vomiting in spite of the empty stomach. This way the vomitus will not enter the windpipe.


The danger of general anesthesia is generally exaggerated. There is only a risk of 3 fatality in a million cases and not 1 per cent as some doctors has claimed.


This was my first case of general anesthesia.
Once you have done a few cases, it becomes easy and almost automatic.