By Malcolm Fisher (World Medicine October 1976)
“Surgeons and anaesthetist have a curious sadomasochistic relationship.
The love-hate aspects of the relationship are governed by two historical truths: without surgeons, anaesthetists would be unemployed and, because all surgical progress has been made possible by
anaesthesia, without anaesthetists, most patients would rather keep their gallbladders, prepuces, and ugly noses.
As surgery has progressed and become more horrendous the function of the anaesthetist has changed from providing good operating conditions for the surgeon to saving the patient from the surgeon. As one cynic put it: “They will do a brain transplant one day, just as soon as I can work out which bit to wake up”.
I got my first insight into this unique relationship when I changed from being a surgical resident to being an anaesthetic resident.
On my first day I learned the basics from someone who, while unknown in scientific circles, is regarded highly in the antipodes as an anaesthetic philosopher. In my first five minutes he taught me the three fundamentals of anaesthesia.
* “Always check the oxygen supply.”
* “Always identify the patient and the operation.”
* “Hate all surgeons and hate the slow bastards most.”
I was a little taken aback but I soon learnt that these rules, like many other things he told me, were essential for survival.
On my second day, he initiated me into the inner circle which knows the Cook’s three laws of surgery:
* Surgery begets surgery.
* The adjustment of an operating light is an immediate signal for the surgeon to place his head at the focal point.
* No substance is more opaque than a surgeon’s head.
After three weeks I believed I had anaesthesia mastered, much so that I asked a surgeon what the difference was between a three week resident anaesthetic and a twenty year consultant anaesthetic. “Very little,” he informed me brutally. “the only major difference is that when something goes wrong and a junior is anaesthetising, I know, and when a consultant is anaesthetising I find out in the tea room when it is all over.”
I confronted the anaesthetic philosopher with this disturbing information and learnt the next most important lesson.
* “Never tell the surgeon anything. There is nothing he can do and he will only get in a flap.”
* There were only four things he said to tell surgeon in time of crisis.
* “Please get the retractor off the heart.”
* “Could you stop a few bleeders and give me time to catch up.”
* “Could you give cardiac massage.”
* “You can stop now – he’s dead.”
I then went on and learned the complexities of the surgeon-anaesthetist relationship.
I heard of the famous Jones technique of anaesthesia where the anaesthetist stands at the foot of the table and tells the surgeon how to operate while the surgeon’s assistant hold the patient on the table.
I learned that fitness for anaesthesia was a meaningless term; anyone who could lie down was fit, but fitness for surgery was a different matter entirely.
Fitness for surgery can be decided over the telephone by asking who the surgeon is, where the patient is going after, and what the operation is. All the pre-operative examination tells you is how and when.
I learned to understand the prima donna complexities of the surgeon and to recognise when the operation was not going well.
* All surgeons follow the same procedure.
* Adjust retractors
* Reposition assistants
* Make bigger hole
* Change sides
* Order multiple light adjustments
* Ask for more relaxation
* Curse scrub nurse, resident, registrar, health commission, government, anaesthetist, and deity
* Remove alternative organ and close.
Over a few further years I learned the two other important things that every anaesthetist must know.
Surgical textbooks always list causes of excessive bleeding during surgery. They include incompatible blood transfusion, massive transfusion, poor position, halothane, ether, patient too light, patient too deep, hypoxia, hypercarbia, straining, and so on. They never mention scalpels, tearing vessels or swabbing away clots.
In fact when a surgeon glares ” Can you do anything about the bleeding?” the best reply is “Certainly, but who will mind the patient while I scrub?”
There is also a list of great surgical lies which every anaesthetist will recognise.
* “Put him to sleep, I’ll be down in five minutes.”
* “He is old but he is fit.”
* “You will like her, she’s an old dear.”
* “I haven’t cross matched blood, we don’t need any.”
* “Don’t put a tube down, it’s just a quick snatch.”
* “I’m just going to open, have a look, and close her.”
* “She will die if I do nothing.”
* “I’ll be finished in ten minutes.”
Surgeons appreciate a reciprocal number of anaesthetics lies as they appreciate the law that fitness for surgery is universally proportional to time of day. And let surgeons beware when they hear:
* “The blood pressure is 123/72.”
* “The patients is maximally relaxed and won’t breathe for a week if I give any more.”
* “It’s not cyanosis, it’s just the bloody lighting.”
* “Don’t go away, it will be two minute turn around.”
The subliminal implication of the lies must be appreciated by both members of the relationship if they are to function in the best interest of the patient, and perhaps the greatest advantage of the lengthening postgraduate courses is to give fledgling surgeons and anaesthetists time to appreciate the idiosyncrasies of the other.
As another cynic said: ” Anaesthesia is the half asleep watching the half awake being half murdered by the half-witted.”
Only the other day when my colleague in the next theatre was complaining bitterly: “What can I do about my mother-in-law?” the surgeon withdrew his head from the thorax and snapped:
” Why not give her one of your anaesthetics”