Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 65, Num. 1, 2003, pp. 41-43

Indian Journal of Surgery, Vol. 65, No. 1, Jan.-Feb. 2003, pp. 41-43

Perspectives of Rural Surgeons

Anaesthesia in Rural Practice: How I Do It?

Sanjay S. Shivade

Savitri Hospital, Lonand, Tal.- Khandala, Satara 415521
Address for correspondence: Dr. Sanjay S. Shivade, Savitri Hospital, Lonand. Tal.- Khandala, Satara 415521, E-mail: drshivade@rediffmail.com

Paper received: June 2002
Paper accepted: October 2002

Code Number: is03007

INTRODUCTION

The word 'Anaesthesia' comes from the Greek word 'Anaistheto,' meaning insensibility. 150 years ago, William Morton, a surgeon, successfully demonstrated the use of diethyl ether to induce general anaesthesia. Thus started the era of 'insensible' surgery and surgeons themselves were anaesthesiologists. Anaesthesia induced and maintained on ether remained a gold standard for almost 100 years. Today administering anaesthesia has become a speciality in itself and a branch of medicine. In the last decade, this branch has made enormous progress by the addition of new drugs, machines and some very modern gadgets making surgery that much easier, safer and of course painless. India is a huge country, divided into two main classes. The urban population comprising 25 to 30 per cent of India's population has access to most of the modern developments in medicine. However more than 70% of this country's population lives in the villages, with poor communications, inferior facilities and a dearth of specialists. As a result maternal and perinatal mortality is high. Common conditions like hernia, hydrocele, septic wounds, emergencies like obstructed labour, acute appendicitis, duodenal ulcer perforations, blunt trauma to the abdomen or the thorax, minor and simple fractures have to be treated by a general surgeon who lives in the vicinity. Such a general surgeon is a "Jack and Master of all", including the technique of administering anaesthetic agents as well as inducing regional analgesia. There is no denying that thousands of surgical procedures have been performed in this manner and as a result an equal number of lives have been saved. The author wishes to share his experiences of having performed more than 15, 000 operations (anaesthesia included) at a place called Lonand, which is not even a taluka headquarter. The experience extends over a period of 13 years.

THE PRACTICE

In a set-up like the one described earlier, the practitioner should have had exposure to the practice of anaesthesia, should have gained confidence in performing endotracheal intubation and must be fully aware of the pharmacology of all the drugs that a practitioner will use on the patients.

In the beginning, such a surgeon should have acquired the following equipment related to anaesthesia:

• Ambu's bag or Lardel's bag
• Laryngoscope with three blades, spare bulbs and battery cells
• Endotracheal tubes of all sizes

a) Plain endotracheal (ET) tubes (1 to 6)
b) Cuffed ET tubes (6 to 10)

• A set of airways
• Oxygen cylinder (preferably two)
• Maggill's forceps
• 'KEM bottle' with its connection or EMO circuit with its connections
• Schimmal Buch's face mask (two sizes) for open drop anaesthesia
• Foot suction

After the surgeon starts to undertake major surgery, and depending upon the economics, a few more gadgets can be added:

• Boyle's apparatus with closed circuit and Pediatric circuit
• Spare laryngoscopes
• Jumbo oxygen cylinder
• Separate anaesthesia trolley
• Electric suction

As the practitioner grows and is exposed to meetings, workshops and conferences, he can undertake more complicated techniques in surgery as well anaesthesia, and then procure:

• Pulse oxymeter
• Ventilator (preferably of an Indian make)
• Cardiac monitor with defibrillator
• Oxygen concentrator

A rural surgeon must have a large stock of emergency drugs, which may not be easily available with the local distributors and the local outlets.

The author's protocol for safe anaesthesia is as follows:

1. Thorough examination of the patient (surgical as well as medical).
2. Optimum investigations needed for surgery and anaesthesia.
3. All machines, oxygen and nitrous cylinders, laryngoscope, suction machine and drugs should be checked by the practitioner himself / herself. Untrained staff should never be relied upon for this purpose.
4. Preoperative correction of fluids, electrolytes, loss of blood, shock etc.
5. Proper and separate written consents for surgery and anaesthesia and its complications.
6. The following cascade should be resorted to by the practitioner: a) local anaesthesia b) local neural block c) regional analgesia d) general anaesthesia should be chosen as the last resort e) sedation with local anaesthesia or even general anaesthesia with local infiltration can be quite useful.
   
   The practitioner must at all times know the maximum dose of local anaesthetic agents per kg body weight of the patient.
   
7. Always obtain intravenous access, preferably in a large vein and preload the patient with a fluid of your choice (according to the weight of the patient). It prevents intraoperative hypotension and its sequelae.
8. All the patients with borderline anaemia, should wear an oxygen mask during and two hours after an operation, possibly to prevent tissue hypoxia.
9. Even if the surgeon is performing a procedure under LA, SA, EA, a medical professional should always be on hand to monitor vital parameters during the
   surgical procedure.
10. If the patient has come immediately after a meal, put a stomach tube and empty the stomach. Use gastrokinetic and gastric emptying drugs before anaesthesia, wherever necessary.
11. Most Important: Avoid performing surgical procedures in cases of 1) Ischaemic heart Disease (IHD), 2) uncontrolled diabetes mellitus, 3) very advanced age, 4) obvious poor respiratory reserve, 5) very small children, 6) Rheumatic Heart Disease (RHD), 7) Multi-organ failure, etc. The practitioner must be prudent and must refer cases with the above conditions to nearby institutions, as well as when he is short on help and equipment. A surgeon may be fearless of his reputation but not about patient safety.

CHOICE OF ANAESTHESIA

a) Surface and/or local infiltration: In my experience, the rural population has a higher ability to tolerate pain as against the urban population which is hypersensitive to pain, over-anxious to operative procedures and probably demand more comfort too. Surface or local anaesthesia should always be the first choice. It can be combined with some sedation and analgesia. The most common drug used is xylocaine. One should be aware of the accurate dosage of this drug, The following procedures can safely be done under LA:

1. ENT: Tonsillectomy, SMR, septoplasty, thyroidectomy, tracheostomy, lymph node biopsy, superficial benign swellings of the head, neck, face, tongue tie, salivary gland removal, tooth extraction, inter-dental wiring for fractures of the mandible.
2. Abdomen and genital, urinary: Hernia, hydrocele, orchidectomy, circumcision, urethral dilatation, partial amputation of penis, appendicectomy (selected cases), putting drains in the abdomen for a patient who is unfit for GA or SA (for example, perforation peritonitis septicaemia with poor general condition), cystostomy, aspiration of liver abscess or residual abscess etc.
3. Gynaecology: Caesarean section, D&C, repair of only rectocele or cystocele by vaginal method, vaginal hysterectomy for procidentia, incision for haematocolpos, Bartholin's cyst, tubectomy, etc.
4. Chest: Putting ICT drains, medically unfit cancer breast, benign breast tumours, plural effusion etc.
5. Orthopaedic and soft tissue: Fracture and fracture dislocation of fingers and toes, small area skin grafting, bone traction for fractured neck and femoral hip dislocation, 'K-wiring' for small bone fractures, pedicle flap for upper or lower limb under brachial or femoral blocks etc.

b) Regional Anaesthesia: The author practices regional anaesthesia either by giving nerve blocks, spinal anaesthesia or epidural anaesthesia. Eighty per cent surgeries can safely be done under either local or regional anaesthesia in rural practice. Practically all major, elective, abdominal, gynaecological, lower extremity, urological operations can be safely done. The list of operations would cover almost all the major elective and emergency operations done by a general surgeon in rural practice. To avoid excessive sympathetic blockade and resultant hypotension, the author prefers to give unilateral spinal anaesthesia for cases like hernia, hydrocele or operations on only one limb. Low spinal can be a good choice for operations on the anal and lower GU tract.

c) General Anaesthesia:

1. The author prefers open drop anaesthesia for certain short duration paediatric operations. For example for circumcision, herniotomy, all fractures, abscess drainage, superficial injuries, superficial or ear foreign body, induction with ethyl chloride and maintenance using ether is quite safe. Pre-anaesthetic medication is mandatory. Regurgitation and vomiting is troublesome but not fatal. It is wrong to say that open drop anaesthesia has been outdated. In the author's practice, it has been used even for adults in more than 2000 procedures without a fatality.
2. Anaesthesia with intratracheal intubation: The author prefers this form of anaesthesia for surgery involving long duration. After proper preoperative check-up the choice of the anaesthesic drug is made. For example, Ketamine in the dose of 1-2 mg/kg or sodium pentothal in the dose of 7-10 mg/kg. It is always better to pre-oxygenate the patient for five minutes. Intubation is done with the help of relaxation obtained by administering succinyl choline (1-2 mg/kg). Patient can be kept on spontaneous breathing using ether + oxygen or ether + air. If electrocautery is to be used, it is better to give long-acting muscle relaxants intermittently and use less anaesthetic agents.

If the rural surgeon is accustomed to few common anaesthetic drugs, then it is not very difficult for him to practice anaesthesia. For a short procedure, only pentothal sodium or ketamine can be used.

CONCLUSION

A rural surgeon/ anaesthetist must deliver by first assessing, then training, adapting and along the way by innovating. That must remain his path as he serves a certain population. He will be frustrated if he dreams of high-tech surgery in a modern setting. In many ways a rural surgeon/anaesthetist are missionaries and must remain so. A spouse (either husband or wife) who is an anaesthetist will help.

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