okay so let's get on to surgical issues now i find this is something that i very rarely did
when i started off and again it will have a lot of advantages to you so um just put your hands
up has anyone had difficulty talking to a surgeon you know i think that's everyone like if everyone
if no one has had difficulty talking to the surgeon hats off to you because you know you're an
amazing person so the reason i ask these surgical issue questions is not just about
the answer i so i don't want just information i want to start a conversation with someone who's
generally speaking on a higher hierarchy than i am the fact that i'm a consultant now has
some weight but definitely during your training it's going to be one of those things where you'll
be the most junior person in the theater and you want to just start a very cordial conversation
with them about relevant things it breaks down a bit of the hierarchy that might exist
and it shows that you're a bit assertive and you want to know about your surgeon's needs and
think about that you're asking them for what they want it's a very good way to start a conversation
versus hey i need you to stop the surgery i'm worried about the patient that's very obstructive
and what you're doing here is being very you know cordial very very accommodating to the surgeon's
needs for yourself and for your boss it just shows a lot of awareness if you know how to ask these
questions and get you know good at asking them and considering them and again as i mentioned i want
the first interaction that you have with someone who's potentially higher on the hierarchy scale
again the hierarchy which i don't agree with um but let's say they're on that hierarchy scale i
don't want that first interaction for you to be in a crisis when you're alone in theater
and something bad is happening and you've got to whisper hey do you mind stopping i need to sort
this out and the surgeon looks back at you with other contempt because you're you know they're
in their thing doing they're doing their work and you're asking them to stop what they love
doing let's take a couple examples and again talk it through with your partners uh an mva trauma
patient 24 year old presents urgently to theater for laparotomy uh with free fluid in the abdomen
uh and with a splenic rupture what questions do you want to ask the surgeon i just want to address
some really great questions in the chat i'm sorry i didn't address those before in the aspirational
situation would you ever put a nasogastric tube i'd say the culture is that most people especially
for reflux would never put a nasal gastric tube inside you for something like bowel obstruction
nasogastric tubes will already be put in but there was also a court ruling that a lot of
australian nieces know about and are taught about that there was a court ruling when a patient had
an aspiration event that they said if the if a nasogastric tube is already in you should aspirate
that with one of those large syringes prior to inducing anesthesia and that's something i'd
routinely do if they for whatever reason don't have a nasogastric tube there's no recommendations
to suggest you would do that just for the surgery if you are really passionate about it
the patient's vomiting a lot or you know whatever it is i don't think it's the you know worse thing
for you to do that but that's that's where the culture of anesthesia stands at this point in time
aspiration during anesthesia is very rare and a lot of the things that we do are very good at
preventing it aspiration often occurs not in where you expected in that small time frame of induction
it's often not the place aspiration occurs it's often in things like having an lma anesthetic
where the patient does reflux slowly over a long period of risk time it's often not in that short
period of an induction just to give you a bit of perspective you'll see that as you go through your
training yeah would you consider regional block often people especially surgeons and when i was
in my junior levels of training i thought that regional block would be the answer for
mortality morbidity so just to know that there's no morbidity or mortality evidence for regional
over general anesthetic just think of the impact of that that was very new to me until i saw the
studies on this the mortality benefit of mobility benefit regional over general anesthetic doesn't
exist it has pain advantages but very rarely will you have a you know problem doing one or
the other and then someone says navigating high-risk patients in the anaesthetic bay
not great right but it's the whole sunk cost fallacy if you need to have a conversation
with someone it doesn't matter you know just because you're all the way up to the operating
theater there are occasionally times when we've gone straight back into the anaesthetic room
when we've decided that this patient hasn't consented correctly so it's all no matter
how late in the game it is it's always a good time to have it have the right conversation
okay just to go back to that sorry about that little side track and what do you want
to ask the surgeon how long do they think the surgeon the surgery is going to last for right
and how much blood loss is there going to be there's going to be some free fluid how much yes
and given that it is a laparotomy i've been considering you know what type of incision do
they want to make where to make it i think about if there's up if the laparotomy scar is very
big i'll need far more pain medications i also think about what regional technique i could do
if depending on where that laparotomy lesion is you know whether i can do tap catheters or rectus
sheath catheters or or whatever it is uh keep going that's really good so position duration
expected blood loss where the um uh incision is and then the other basic things that you'll always
remember because it's on the surgical safety checklist antibiotics as well as dvt prophylaxis
now when you mentioned bloodlust i thought that was really great because i often have a very
detailed discussion about this because i don't know what the surgeon knows and i need them to
really communicate with me so i might ask for you know special requests like does this patient need
a cell saver or not i want to give you a bit of insight about how detailed i get with this
conversation and the fact that this is definitely something you can still have i had a patient
uh having a very difficult angio repair in a remote environment so in the angio suite
away from theater they had some kind of bleed in a vessel that was in their in their chest
and so the conversation i had to have is how this patient is bleeding now how likely are
you to make the bleeding worse how rapidly will that bleeding loss occur so i'm thinking okay
do i need to get a whole bunch of stuff in there the rapid infusion devices like the level one do
i need a massive transfusion ready and set up in this remote location and a couple of extra hands
and do i know if the if the surgeon can actually repair this lesion as well so
how long are you likely to have catastrophic bleeding for and if you need to go to theater
how soon will you know and do i need to plan for theater straight away just imagine how nuanced
and how subtle that discussion has to be for me to know exactly what i need to do that's rarely
happens but i just want to give you a bit of insight so position duration blood loss expected
antibiotics and dvt prophylaxis these are pretty standard questions for every operation and then
there's this special stuff cell saver how much blood loss and all that detail stuff but that's
great let's keep going through those 35 year old with a deep forearm laceration for ulnar nerve and
artery repair what do you want what questions do you want to ask the surgeon i would ask about the
direction of the case um what position they need to be in if they need to be paralyzed
um amount of blood loss expected if they need what aunties they want dvt prophylaxis and
then if they need any other teams involved like vascular or plastics fantastic is there anything
and there's one extra thing so that's absolutely right if you were to ask those questions and you
know inform you later i'll be very happy because you've sorted out stuff that i want that i had
to do anyway um when they're doing nerve repair sometimes they need to do stuff with the nerves
oh yeah really like monitor like like no simulation like nerve stimulation
yeah and in so yeah exactly and do i need to do anything special if there's nerve monitoring
so you might want to avoid muscle relaxation because the way they monitor the nerve is by you
know checking where there's a muscle response uh when they monit when they stimulate the nerve so
that's it i might need to avoid muscle relaxation or prove to the surgeon that i'm not giving muscle
relaxation also you might want to use a tourniquet as well um but again the surgeon usually takes
care of that total thyroidectomy what questions do you want to ask the surgeon obviously going
through the same normal five things yeah um particularly in terms of positioning and who
probably wouldn't be more upright but obviously surgeon's preference yeah duration blood loss um
antibiotics deputy prophylaxis but um obviously three more specialized surgery in terms of the
incubating equipment and the surgeons taking particular care like recurrent laryngeal
nerve that sort of thing yeah what do they do that's exactly what what the special request is
um have you have you seen much thyroid stuff do you know what tube i'm talking about or thinking
i haven't seen one but is it something to do with that has like it's also got some nerve monitoring
exactly exactly it's called the nimtube nim or neural integrity monitor tube so again i
want to avoid muscle relaxant and i want to use a nim tube and it's a just a special placement
that you put this floppy reinforced tube that's a bit larger down and have the black electrodes
across the vocal cords something that you'll see in their thyroid cases and you'll never think it's
difficult ever again the one thing about this is interesting because it really matters to me
the position of the arms is really important so when i think of position i definitely think of
what you're thinking whether the head up or prone or you know whatever position it is but when the
arms are in it means that i don't have access to my cannula or my art line if that's if that's
relevant um so yeah that's it's one of those other things that i always ask so i know where
to put my drips in or whether not to run tiva if i'm worried about what you know witnessing the uh
prep for going in okay let's go to this case 55 year old for vocal cord nodule excision and biopsy
what questions do you want to ask the surgeon standard questions
physician indication um antibiotics uh i'm not sure if for this procedure they might use a nym
tube or something similar because of damage to the nerve
and that's a good thought but it is about the tube if i if you were a surgeon what do you there's
something that you want that i don't want you to have because it gets in my way you go oh i guess
the tube itself will be absolutely that's exactly right um when surgeons are all about exposure and
access and we're all about control and those two don't always match and so the special
requests i have for this so again exactly you said all the usual stuff position duration
antibiotics dvt prophylaxis and then what kind of airway would you prefer and i encourage you again
as a bit of a tip when you're in your ent theater ask ask for them to use something a bit different
there's all these different airways that you'll use in ent cases like such as jet ventilation
through supraglottic devices trans tracheal devices like a hansika or benjet tubes and
these are things that i've often do in my training just asked if i could use them just to be able to
see how to use them because they're not very commonly used the final thing as well in ent
surgeries often like say for fast surgery fun functional endoscopic sinus surgery is to have
a throat pack or something like that um so again things you wanna you wanna know about and to ask
let's go with this case um cesarean section with placenta previa and potential accreta
uh what questions you want to ask the surgeon and any special request for this and for those that
don't know placenta previa with a creator is just a ridiculously high bleed risk um and it's you
know just the worst bleed risk you can imagine next to having a ruptured triple a um so just
a hint but there's a lot of things i can do to help mitigate that problem i guess the usual five
things that we've already discussed the position may be more important here the duration of surgery
and dvt prophylaxis and obviously in this one especially the expected blood loss of the surgery
absolutely i'd like to know if we've got recent coags and access to tech monitoring throughout
the case absolutely um because of the blood loss is there anything you could do to help
with that blood loss so i definitely want all that monitoring rotamore tag
and again like getting all the right blood results to understand whether this patient has a group
and hold valid cross-match with no antibodies so i don't delay it because i'm worried about
massive transfusion and in this particular case cell saver can be used in pregnancy but also
the fact that i might need two surgeons and one of those surgeons i may i often would get say a gynae
gyne onc surgeon because they're very good at hysterectomies because that might be where this
needs to go very very quickly and i might even have two anaesthetis as well 88 year old severe
pulmonary hypertension for nail bed repair on finger again what questions one do you want
to ask the surgeon so yeah the usual things that we've discussed uh definition duration expected by
those antibiotics and dvd prophylaxis but i guess more significantly we probably won't need ga for
this particular cases they're happy with regional that's perfect that's exactly what i want you to
ask um plus plastics is one of those lists where you'll get lots and lots of patients who are quite
elderly with lots and lots of comorbidities and the surgeons are so good in just like you said
having everything done under local anesthetic with very minimal if no sedation so special requests
can we avoid general anaesthetic and that makes everyone stay a lot less stressful so that's great
um and again this is just a very specific part of the anaesthetic plan in the sense that i'm asking
the surgeons about what they need and what they can you know accept and i'm not doing my full
anaesthetic plan just to keep that separate um someone's asked a really good question about
for high-risk placenta previa would you consider going with general anesthesia from the get-go and
absolutely so most of these high-risk bleed cases in pregnancy we would do that straight away and
that will be part of the anesthetic plan but something again you could ask the surgeon look
you know i'd almost offer that i'll i'll be doing a general anaesthetic hope that's alright
with you so surgical is in summary position duration blood loss antibiotics dvt prophylaxis
and then a whole bunch of special requests that again i want you to be aware of now to show that
you have insight and this is actually really easy stuff to learn you know once you know it you know
it it's not it's not difficult at all and stuff that uh through my years of training uh junior
registers aren't thinking of uh straight away uh and hopefully this will keep you looking pretty
good uh any questions before we move on i think there was a question oh yeah absolutely that's
a good question i'll answer that so um if you have bleeding risk it's either going to be due to these
four things tissue tone thrombin or trauma and so that's the broader aspect of how i'd address this
um so tissue that's exactly why this bleed is happening because there's tissue retained and
that's you know my primary problem um trauma often not in this situation but i'd address that as well
and then thrombin after a lot of blood loss or pre-existing problems um i'd need to address
that and i'd you know constantly replace factors use rotamod tag to constantly do that and reassess
but in the specific part of tone that's exactly right so i would uh volatile is um causes uterine
laxity so i'd use propofol or run low volatile and nitrous um and then i'd address all the other
things such as giving cintosinone um ergometrin prostaglandins like such as carboprost as well
yeah it's a good question we never seem to have a cell saver so often hospitals that aren't big
trauma hospitals have to call in a cell saver and you have to call them in
you have to book them in or call them in with a lot of prep time so the last time ruptured um
vessel that i had to deal with just um this week we couldn't get cell saver booked in so you know
if you're planning for something you definitely have to plan for it early in smaller hospitals you