Saying no when it is important
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SAYING “NO” WHEN IT IS IMPORTANT. DR.S.N.KRISHNAMOORTHY M.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”.

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SAYING “NO” WHEN IT IS IMPORTANT

DR.S.N.KRISHNAMOORTHY

M.D., D.A., D.N.B., B.G.L., P.G.D.M.L.E.,


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SAYING “NO”

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

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


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Saying “No”

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


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SAYING “NO” IN ANAESTHESIOLOGY

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


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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.


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WHY THE OCCASIONAL NEGATIVE APPROACH?

  • 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.


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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.


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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.


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SAYING “NO”

CLINICAL SITUATIONS>>


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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.


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GA IN A PAEDIATRIC PATIENT WITH ACUTE RESPIRATORY INFECTION AIRWAY

  • Acutely inflamed respiratory passages.

  • Instrumentation leads to high incidence of bronchospasm / laryngospasm.

  • Completely avoidable.


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GA IN ACUTE RESPIRATORY INFECTION AIRWAY

  • IT IS ON THE PATENCY OF THE BRONCHIOLAR

    LUMEN AND QUIESCENE OF RESPIRATORY

    REFLEXES THAT SMOOTH GENERAL ANAESTHESIA

    DEPENDS - NOSWORTHY


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PATIENT “UNFIT” FOR ANAESTHESIA AIRWAY

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

  • Co-existing Anaesthetic problems

  • Meddlesome anaesthesia


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Patient unfit for anaesthesia AIRWAY

  • 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


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Denial of anaesthesia services AIRWAY

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


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ANAESTHESIA FOR PARTIAL RESPIRATORY OBSTRUCTION AIRWAY

  • 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


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DIFFICULT AIRWAY SITUATION WITHOUT AIRWAY GADGETS AIRWAY

  • Many airway gadgets are available today

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

  • Airway management is the exclusive responsibility of anaesthetist.


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LACK OF BASIC MONITORS/INVESTIGATION AIRWAY

  • 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.


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WHAT IF YOU DO NOT SAY NO? AIRWAY

  • 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.


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WHAT IF YOU DID NOT SAY “NO” AIRWAY

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


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“CRIMINAL NEGLIGENCE” AIRWAY

*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


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CONCLUSIONS AIRWAY

  • “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.


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THANK YOU! AIRWAY