Before I entered the Anesthesiology department, I didn’t know anything about it. I mean, I had the preconceptions that everybody else usually has: anesthesiologists give sleeping gas to patients undergoing surgery and then themselves sleep during the surgeries. I had heard throughout my life that they’re the laziest doctors who get paid a lot to do the least amount of work. Okay, that’s not actually true of course. Well, they do sometimes fall sleep during surgeries 😀 but it’s rare and it depends on the type of surgery. I will explain… Let’s define anesthesiology first.
I will try to use the fewest words: anesthesiology is the branch of medicine that deals with keeping a patient alive in critical situations. What is “critical situations”? It’s when if there is no intervention by a doctor, the patient has a high chance of dying. Surgery and being under general anesthesia are critical situations. General anesthesia is the act of putting a patient in a very deep sleep where if it is too deep, it can be permanent (the patient dies). So, when general anesthesia is given during surgeries, anesthesiologists are always present.
They make sure the patient gets enough of the right sort of anesthetic meds (I’m over-simplifying here to keep it simple) to not feel any pain but also not die. But wait – let’s not stray too far here. I told you about the definition of anesthesiology, right? Well, as you would’ve noted, it’s a pretty broad definition. I mean, “critical situations” can be anything, like a broken leg in the ER or a patient taking his last breaths in the ICU. Well guess what, anesthesiologists work in the ER and the ICU also. In some places, these doctors are sometimes called “intensivists” because they work in “intensive care” units (ICUs) or “EMs” (emergency medicine) specialists.
But in Indonesia and many other countries where they don’t have intensivists and EMs, the work of keeping patients alive in critical situations is done by anesthesiologists. So, what exactly do anesthesiologists do? Until now I keep saying, “keep patients alive” but I’ll try to be more specific (for the unimaginative among us). They’re always watching the monitor for the patient’s vital signs: blood pressure, oximeter reading, heart-rate, breathing, and ECG – usually in that order. They’re also constantly making sure the fluids are balanced and there is no danger of shock or acidosis/alkalosis. As you can imagine, this requires a good anesthesiologist to have sound understanding of the cardio-vasculo-respiratory system along with the kidneys and GIT.
Maybe many people don’t realize it but the anesthesiologist is one of the doctors who visits them the night before their surgery. We call this visit the “pre-op”. During the pre-op, we ask a lot of questions that then help us decide what sort of anesthesia the patient should be given and how risky the surgery is. We come up with an “ASA score” based on the result of the pre-op and the lab results (which we have to pore over during the pre-op). If it’s “ASA 1″, it means it’s a low risk surgery and if it’s a higher ASA such as ASA 3, then we may have to consider postponing the surgery if it isn’t absolutely necessary. During the pre-op we find out history of operations, past and current illnesses, and even things like false teeth.
Why are false teeth important to know about? Find out in the next paragraph… One very important thing that anesthesiologists do that I forgot to specifically mention is: airway management. During coma (e.g. coma induced by general anesthesia), the patients may not be able to breathe themselves (properly). So, we have to make sure that we use an airway device such as an endotracheal tube (ET) and a ventilator to help the patient breathe. During the pre-op, we need to find out which is the safest and best airway device to use during the operation. We do this by assessing the Mallampati score – which is basically to see how small their throat is – among other things. Mallampati 1 means you can see their uvula and a pretty poor Mallampati of 4 means that you can’t see any part of their throat from inside their mouth. We measure the opening of their mouth and the distance from their jaw to their neck and then from that point on the neck to their adam’s apple.
The scale we use to measure isn’t centimeters or inches. Instead, we use the patient’s fingers. It’s easy and fast. So, if you haven’t figured out why we ask about false teeth by now, let me explain: when we’re inserting an airway device in the patient’s mouth, there’s a (high) chance that we’ll be accidentally hitting the teeth with it – and there’s a risk the tooth may come off and fall into the throat. There are other reasons also: if a patient has no teeth, then their mouth would be smaller and thus, more difficult to insert airway devices in their mouth. The anesthesiologist’s job (in the operating room) starts with the pre-op (in the ward) the night before, as I’ve described. Then, the next morning, the anesthesiologist is the first one in the operating room. Wait.
Instead of talking about “the anesthesiologist” in the third person, I’ll just talk in first person as if I’m in the anesthesiologist. Okay, so, the next morning, I am the first person in the room (and no longer speaking in the third person – Sorry). I check the patient manifest (as I like to call it). I see the age and the weight of the patient next to their name and type of surgery. I check my notebook and I’ve already done all the calculations (with the help of the Anesthesiologist Android app) for the medications and fluids for this patient. Great. I smile alone in the bright operating room as I notice that those meds are stocked on the little anesthesiology cart parked near the head of the operating table.
All of them are in glass ampule bottles. Careful not to cut my finger, I remember to turn the dot printed on the ampule towards myself, place my forefinger on the opposite side, grasp the top of the ampule with my thumb, hold firmly, and break the ampule’s neck over my forefinger while simultaneously applying an upward force using my thumb. I hear a “pop”. I pause. No blood. (the pain always comes later, so I check for blood first). Okay, no blood. No awkwardly broken glass. My latex gloves aren’t ruptured either.
Awesome! I then expertly turn the ampule upside down, insert a needled syringe in with the other hand, and pull the liquid drug into my syringe faster than you can say “anesthesia”. I do this 4 to 8 times, loading syringes like ammunition in guns before a battle. Then, I check the equipment required for the airway. If it’s supposed to be ET intubation for example, I get the correctly sized laryngoscope and blade (making sure to check them), throw my stethoscope over my neck, grab a couple of ET tubes, connect the suction tube, find an OPA/MAYO, a stylet (pfft… nobody uses those anyways), and check the oxygen. While I’m thinking, “what else, what else… what did I forget?” the doors open and the patient is brought in. There’s an awkward transferring of the patient from their guerney to the operating table.
I grab the bottle of infusion fluid (usually ringer lactate) and hang it. I make sure the patient’s arms are out sideways and bound, sort of like Jesus on the cross. Either there’s a 3-way stop-cock or just a bulging ball thingy on the IV cannula. With the 3-way stop cock, I have to screw off the needle off the syringe, screw the syringe on the stop-cock, turn the stop-cock to open it, and then push the drug into the patient. It’s easier with the bulging ball thingy: I just stab it with the needle of the syringe and push the drug. Then unstab and I’m done.
Drugs are pushed into the patient before the patient even realizes that anything is happening. The patient is usually very quiet and looking scared – sometimes even praying. The operating room staff often talk to each other, pretending the patient is an object or isn’t even there. It’s weird but that’s just the operating room culture here. The patient might feel everybody is really relaxed and waiting for something. And they’d be right. They’re all waiting for the anesthesiologist to give the go-ahead. And the anesthesiologist looks like he’s waiting too.
His eyes dart from the monitor to the clock, and then to his notebook, and then to the patient’s face and then quickly towards the anesthesiologist’s cart – remembering suddenly: “Omg, I forgot the syringe used to inflate the cuff on the ET!” Eventually the drugs do their magic and the patient seems to fall asleep. If there was a moment when the 80s action music would be queued, it would be now. The anesthesiologist’s heart-rate goes up, pupils dilate. All eyes in the room are now clearly fixed on the anesthesiologist, except the patient’s of course – they’re closed. Very gently but quickly, I graze the patient’s eyelashes.
The patient doesn’t flinch. This is it. I perform the triple maneuver – with just enough strength not to look strained (or break the patient’s neck) – and then, using the mask connected to the oxygen, I oxygenate the patient, preparing them for what I’m about to do to them. The surgeons stand there, fingers criss-crossed in front of them, waiting for the anesthesiologist’s next move. It’s the most interesting part and nobody in the room wants to miss it. Time ticks and tocks.
The anesthesiologist knows what he’s doing. The lungs have something called the FRC (functional residual capacity). This is like extra space that we can saturate with oxygen, like an auxiliary tank of fuel, so we can get up to 5 minutes to insert tubes without the need to give the patient any air. So, despite the oximeter showing 100% oxygen saturation, I keep holding the patient’s jaw with my middle, ring, and pinky finger with the mask affixed on the face with my first finger and thumb. My other hand squeezes the rubber bag to manually deliver breaths to the patient.
The squeezes look random, but they aren’t. One eye is on the patient and his rising-falling chest, and the other bounces like a ping-pong ball between the monitor and the clock. This is probably how famous figure-skaters feel: they know the world is watching but they have to focus so hard not to mess up that they can’t even spare a moment’s gaze or thought on their audience. Another milestone hits. Without taking a single step away from above the patient’s head, I pull the oxygen mask off. A mental countdown clock starts as the oxygen in the FRC starts diffusing into the lungs.
With hands as stable as a horse, I snap the laryngoscope together, yank the patient’s head back, shove the metal blade in their throat, bend over forwards and down slightly, and with the other hand, insert the ET tube into the correct hole (the breathing hole, not the swallowing one). A stethoscope is then used by an assistant on the lungs and the stomach. It is like a referee being given a chance to decide something very critical. He nods and gives a thumbs-up. I sigh with relief and continue bagging while using tape to stabilize the tube which is now going from the ventilator to the patient’s lungs (almost). The tension in the room eases.
More drugs are pushed into the patient. The surgeons are given the okay and they begin their butchering and gossiping. The anesthesiologist may look relaxed during the surgery but he’s constantly listening to the monitor: “beep… beep… beep… beep…” and the second there’s a “boop” instead of a “beep”, the anesthesiologist whips his head to look at the monitor so fast, you can almost hear the swoosh and crack of a bullwhip. And yes, the beeps from the monitor actually mean something. The frequency of the beeps is the heart-rate (everybody knows that) and more importantly, the pitch is the oxygen saturation. Every five minutes, the anesthesiologist has to update everything including vitals and medications onto a chart.
There’s a load of paperwork involved, so it isn’t unusual for there to be a desk provided for the anesthesiologist’s use in the operating room. At the end, the patient is brought back out of their induced coma, the airway device removed in a responsible manner, and the patient prepared for transfer to the recovery room. I accompany the patient until the recovery room and make sure he’s stable and (sort of) awake. Now I can walk back to the operating room and do it all over again for the next patient. At the end of the day, when I’m exhausted, I remember I have “jaga malam” (night shift). Luckily, before that, I have time to shower and eat.
Oh wait, no I don’t. I have to do pre-op. After the pre-op, I rush to the ICU; a sad reminder that anesthesiologists are also intensivists here.