Challenges of anesthesia and regional anesthesia practices in rural center

Vol 3 | Issue 2 | May-Aug 2017 | page: 3-4 | Surajit Giri.

Authors: Surajit Giri [1]

[1] Consultant Anaesthesiologist, National Health Mission, Government of Assam and Demow Community Health Centre, Sivasagar, Assam, India.
[2] Consultant Anaesthesiologist cum Critical Care Physician, Pragati Hospital and Research Centre, and Aditya Hospital and Research Centre, Sivasagar, Assam, India.
[3] Honorable Secretary ISA and Founder EC Member TAS/AORA and WFSA/AARS Fellow, Assam, India.

Address of Correspondence
Surajit Giri,
Consultant Anaesthesiologist cum Critical Care Physician,
Pragati Hospital and Research Centre, and Aditya Hospital and Research Centre,
Sivasagar, Assam, India.

Challenges of Anaesthesia and Regional Anaesthesia Practices in Rural Center

Way back in 2003-2004, when I started practicing anesthesia, I thought that relationship with surgeons and hospital is the key factor in my branch. In addition, I wanted to avoid any interaction with the public; therefore, I had joined the field of anesthesia. However, more than a decade later, my impression about the field has undergone a sea change and today it is completely the opposite! Communication/discussion with patients and public is the key factor for me. I prepare, communicate, and decide remuneration for my work. The journey from 2006 to 2017 has been rather tough and full of challenges! Moreover, it is also that phase of my career where I have learnt the most.

Today I enjoy anesthesia, my remuneration, recognition, and company with my friends, family, and public.

Before embarking on anesthesia practice in small center as a freelancer, I want to put forward the following points for successful practices of anesthesia and analgesia.
A. Survey the local area
What type of surgery, what are the anesthetic techniques, etc., and train accordingly. In rural area, the common surgeries are cesarean sections, hysterectomies, appendectomy, cholecystectomy, hernia, and orthopedic surgery.
B. Train/update/educate
Train, update, and educate yourself according to the need of the survey. If you update yourself in neuro and cardiac anesthesia and want to practice in a small center you are going to fail. As in my area, nerve blocks and post-operative analgesia were not practiced extensively (or not practiced at all), I decided to train myself on nerve block anesthesia. Rural/small area, the surgeons usually dictate everything. To counteract this, you need to be up-to-date with your subject and try to take a lead.
C. Man, machine, and medicines (3 M’s)
3 M’s are always missing in small center. You have to talk/discuss with the hospital authority. Make them realize the importance of 3 M’s in patient safety.
D. Train and educate your staff
Train and educate your staff rather than scolding them. Make them understand the importance of nil by mouth, monitoring, management of local anesthetic (LA) toxicity, etc.
E. Communication
Always have good communication with your staff with their name instead of just “SISTER.”
F. Empower/respect/support your staff
Empower your staff so that they can STOP you if you are doing wrong. Once my operating room sister stopped me as I was about to give nerve block in a healthy leg.
Recently, my technician stopped me as he felt “warm body” during position for spinal anesthesia in an elective cesarean section. The measured temperature was 100°F. We postponed the surgery but the family members went to another hospital where the new surgical team performed the cesarean section and patient landed with reopening the abdomen for post-operative bleeding and ended up with hysterectomy and peripartum sepsis.
G. The WHO surgical safety checklist
It has a huge impact on patient safety. Many errors can be prevented. Initially, it was extremely difficult for me to implement but with
repeated insistence and education of all supporting staff, it is now possible, and we are following it regularly.
H. Resistance from surgeons
Yes, you will get lots of resistance from surgeons. Same thing happened to me. However, continuous discussion and passion and determination help overcome this resistance. They told me these things will not work, but I requested them to give me 40 days of trial period to establish my technique.
I. Marketing
In any branch of medicine, marketing has a great role. Initially, I had practiced my nerve block techniques in small surgical cases such as lipoma, abscess drainage, and ganglion excision as a free service to the surgeons and the patient and ultimately to the society. Gradually, general public and surgeons acknowledged and welcomed my technique of nerve block.
J. Pre-anesthetic communication
Always communicate with the patient and attendants and communicate extensively with them. Assure the patient that he will not have multiple pokes and will not be operated in pain under any circumstance.
K. How to make a nerve block successful?
Always perform the nerve block well ahead of surgical time. If surgery is at 10 am, start giving nerve block at 9 am followed by assessment of nerve block procedures. Always give enough time to LA to soak the nerves. Always remember the 4Ps for upper and lower limb. If block has taken off completely then only go for surgery and incision. Remember for complete analgesia and anesthesia the dermatome, myotome, and osteotome have to be blocked completely. The 4Ps will tell us that myotome and osteotome are blocked, but for dermatome always run an ice cube over the incision and observe whether patient gets the cold sensation or not? If the patient feels cold sensation, ask the surgeon to infiltrate the incision area or go for rescue block if feasible.
L. Accept failure
There is always a chance of failure in regional anesthesia irrespective of their expertise and experience. Accept the failure and go for definitive anesthesia. The short cuts such as excessive sedation and analgesia in block failure patients without securing airways is totally unacceptable and should not be practiced at all.
M. Empower the public
Let the general public know about you! Who are you? What is your role? We are doing it regularly. Give enough time during communication. Let them ask questions.
N. Documentation
We tend to neglect this important aspect in rural centre. However, make a habit of document everything what you have done in perioperative period.
O. Recognition
If you practice standard anesthetic and surgical technique in patient care, the world will recognize you. The latest example is our British Medical Journal (BMJ) recognition for providing standard surgical care in small rural village. It always comes spontaneously to you. The public will also give you the respect and recognition. Because of our services, various organizations of our local area came forward and appreciated our efforts publicly and published both in print and electronic media. Although this was not our goal, it happened spontaneously in our journey.

It is prudent that there are multiple problems in a small center, but we have to remember that, where there are problems, there are solutions as well!

I always believe an anesthesiologist is the leader of perioperative care. If he/she can lead properly, WE as a team can beat anybody in the world and probably South Asia BMJ award is the answer to it.

In this journey, I have been supported extremely by my parents, my wife, and kids. They understood my passion for anesthesia and analgesia and sacrificed a lot for me. It is only because of them, that I stand here today as Dr. Surajit Giri.

I am extremely proud to be an anaesthesiologist.

How to Cite this Article: Giri S. Challenges of anesthesia and regional anesthesia practices in rural center. Journal of  Anaesthesia and Critical Care Case Reports May-Aug 2017; 3(2):3-4.


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