SAYING “NO” WHEN IT IS IMPORTANT

1. 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.,

2. SAYING “NO” • Medical profession is a noble profession wedded to service and sacrifice. • Its services are available to all regardless of extraneous considerations.

3. Saying “No” • Denial of anaesthesia services is justified if actuated by noble and laudable objectives of averting anaesthesia related complications which are anticipated

4. SAYING “NO” IN ANAESTHESIOLOGY • The decision to say “No” is based on the clinical facts and circumstances of the case.

5. 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.

6. 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.

7. 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.

8. 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.

9. SAYING “NO” CLINICAL SITUATIONS>>

10. 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.

11. GA IN A PAEDIATRIC PATIENT WITH ACUTE RESPIRATORY INFECTION • Acutely inflamed respiratory passages. • Instrumentation leads to high incidence of bronchospasm / laryngospasm. • Completely avoidable.

12. 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

13. PATIENT “UNFIT” FOR ANAESTHESIA • Multiple severe & uncorrected physiological derangements and multi-system disorders. • Co-existing Anaesthetic problems • Meddlesome anaesthesia

14. 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

15. 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”.

16. 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

17. 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.

18. 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.

19. 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.

20. 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

21. “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

22. 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.

23. THANK YOU!