A standard day (of elective surgery)
(Not all but a lot of) Anaesthetists start their day with some serious cycling and caffeine at crazy a.m…
We tend to arrive in the department cloaked in lycra at 715-730am and get a ‘list’ of patients we are looking after today. This is usually from the computer system or a list is available in theatre.
Elective lists are lists of patients having planned surgeries. Patients for morning lists are usually advised to come in at 7-730am to the day surgery or admitting unit and they will be checked in and have their observations taken by the nursing staff there. Afternoon list patients will come at a specific time (usually 12pm) and will need to be seen before the list starts.
Patients are given a hospital gown and a bed space or waiting area. Some patients will need pre-operative checks such as blood tests and pregnancy tests. We will conduct our preoperative assessments of patients there (see our First day in anaesthetics – what do we do? for more detail).
The surgeons will also see the patients in the morning to perform the consent process or to recheck that the patients are still happy to proceed and they are appropriately informed about their operation. Operations that have a ‘side’ ie left arm will have the operating surgeons mark the appropriate limb with an arrow (or a smiley face with kids!).
Once all the patients are seen by both teams, a team briefing occurs in theatre with the surgical and anaesthetic teams. Each patient is discussed in a checklist format, so that the surgeons and anaesthetists are aware of the operation and patient details and risks including allergies, scrub staff are aware of the appropriate equipment needed, anaesthetic nurses or operating department practitioners (ODPs) are aware of anaesthetic equipment and plans, and all team members have an opportunity to communicate.
Once the team briefing happens, the patient is ‘sent’ for – usually collected from the waiting area by nursing staff or portering staff. A nurse or healthcare assistant from the admitting area will accompany the patients. Paediatric patients will come with a parent and a nurse and sometimes a play therapist or healthcare assistant.
The patient is checked again in the anaesthetic room (room just outside the operating theatre) to make sure they are the correct person having the correct operation with the correct consent form and the correct details.
Monitoring is applied to the patient, and the anaesthetic commences. At the end of the operation we will take the patient to the recovery area, handover to the recovery team, send for the next patient and start the process again. We tend to try to cover each other so everyone gets a break, because it is important that the patient is cared for by a trained anaesthetic practitioner at all times whilst under anaesthesia, with a clear idea of how to call for additional help if needed. We try to see all our patients after they are fully awake in recovery or the ward to see how they are and provide post-operative advice if necessary.
Other examples of standard days are clinic days where we work in perioperative medicine and pain medicine, and day shifts in intensive care medicine and maternity medicine.
On call shifts
Anaesthetic on call shifts can be very exciting and can depend on what type of hospital you are working in.
We tend to cover an ’emergency theatre’ with cases booked in at short notice for patients with acute pathologies such as appendicitis. Most hospitals have an emergency theatre for general surgery, urology, gynaecology +/- ENT/maxillofacial/plastics/vascular emergencies, and a trauma theatre for orthopaedics. Tertiary centres have emergency theatre provision for cardiothoracic, paediatric, and neurosurgical emergencies. As you can imagine, with so many teams involved in emergency theatres (often one physical operating theatre), good communication, clear decision making and flexible theatre management are key to successfully taking unwell patients through a risky operation safely.
Emergency surgery is categorised by the NCEPOD 2004 guidance as follows:
IMMEDIATE – Immediate life, limb or organ-saving intervention – resuscitation simultaneous with intervention. Normally within minutes of decision to operate.
- Other e.g. limb or organ saving
URGENT – Intervention for acute onset or clinical deterioration of potentially life-threatening conditions, for those conditions that may threaten the survival of limb or organ, for fixation of many fractures and for relief of pain or other distressing symptoms. Normally within hours of decision to operate.
EXPEDITED – Patient requiring early treatment where the condition is not an immediate threat to life, limb or organ survival. Normally within days of decision to operate.
ELECTIVE – Intervention planned or booked in advance of routine admission to hospital. Timing to suit patient, hospital and staff.
The categorisation helps us prioritise patients appropriately especially when the theatre space and support might be needed for more than one patient at a time.
The on call team are often also called to consult on or perform transfers of patients inside and outside hospital, patients requiring an anaesthetic for non-theatre procedures or investigations eg. MRI scans or cardiac catheter lab procedures; patients with difficult vascular access; pain management problems; critical care back up support; and emergencies in wards or the emergency department.
Some hospitals have an anaesthetist on the cardiac arrest teams and trauma teams. The on call team is also the back up for any other theatre in the hospital having a problem eg. anaphylaxis in the anaesthetic room or major haemorrhage.
There is anaesthetic cover at all times day and night for theatres and maternity units. Many anaesthetists also work on intensive care medicine day and night. The great team work and working with almost every professional in the hospital in one way or another is one of the best parts of the job for many anaesthetists.
List order and management
A lot of anaesthesia depends on our ability to make complex decisions for our patients, but we also play a key role in organising the day for the theatre team we are working with, whether elective or emergency theatres.
We work extensively in the pre-operative period deciding whether patients are suitable for having surgery and whether their medical problems can be optimised to make it safe.
This relies on us understanding the patient and the operation they are having, as well as their medical problems and home set up. For example, a 90 year old patient with breathing problems who lives alone and has to have help three times a day having an ankle operation rendering them to mobilise with crutches after the procedure is not a suitable candidate to go home on the same day. They may need their breathing problems optimised by a referral to a respiratory specialist or changing their inhalers. They may need a senior anaesthetist who can perform regional anaesthesia instead of a general anaesthetic. An 18 year old patient with no past medical history who is able to do all his own activities, living at home with his parents and siblings having the same operation would be a much better candidate for going home on the same day even if it is with crutches, and may be suitable for a more junior anaesthetist to care for.
These decisions can be very complex and it is important for us to communicate with various multidisciplinary team members, the patients and their families to come up with a safe plan for them to have their operation.
On the day itself, the list order is often determined after discussion between the anaesthetic and surgical team. For example, if the operating list has 5 patients, of whom 3 are having a day case hernia repair operation, and 2 are having an open cholecystectomy, it would make sense surgically for the 3 hernia repair cases to go first to enable the team to have the same set up and the patients to get home later in the day. But if one of the patients having the cholecystectomy has brittle diabetes and cerebral palsy requiring a carer to accompany them to hospital and a short fasting time, we might have to change the list order to operate on this patient first, before the hernia repair operations and second cholecystectomy. Again – not as easy as it sounds!
After the operations, patients usually go to recovery and stay there for a short time under observation. Occasionally, patients are booked for ‘extended recovery’ services where they need closer monitoring but not necessarily critical care level intervention. We are responsible for the decisions about which patients are suitable for this and which require ‘planned’ critical care admissions after their operation. If they are staying in ‘extended recovery’, we are the medical back up for any patients there and will review them regularly day and night.
Working with theatre teams
There are many members of the theatre teams and each person is important in safe perioperative management of our patients. Here are some of them and their roles:
Anaesthetic nurses/operating department practitioners (ODPs) assist with the anaesthetic
Porters help bring patients to theatre and back to the wards after recovery. They also can help with getting emergency equipment
Recovery nurses care for the patients in recovery and optimise them to return to the ward or assessment units
The operating surgeon – decides on the procedure and performs the operation
Scrub nurses – assist the surgeons with equipment during the operation, they are ‘scrubbed’ in with sterile clothing and gloves
Theatre support workers and ‘runners’ – they are not ‘scrubbed’ and can get equipment and set it up for the team from outside the sterile field
Theatre coordinating nurse is responsible for ensuring the list runs smoothly and supporting the team
Radiographers help with portable X ray guided procedures such as insertion of metalwork, and are responsible for radiation safety
Anaesthetists – performs the anaesthetic and helps manage the list. Usually great chat 😉