Criticare - A special feature on Anaesthesiology

‘The development of anaesthesiology will be slow paced, henceforth’

Dr Dilip Pawar, professor of anaesthesiology at the All-India Institute of Medical Sciences, has about 30 years of national and international experience in anaesthesiology with specialisation in paediatric anaesthesia. Dr Pawar has been associated with AIIMS since 1984 after completing MD anaesthesiology from PGI, Chandigarh. He is the chairperson of the pain committee of the World Federation of Societies of Anaesthesiologists (WFSA) and has been instrumental in forging the relationship of WFSA with Society of Anaesthesiologists. He spoke to Sapna Dogra about various issues in anaesthesiology.

Why is anaesthesia a low-key specialty?

Anaesthesia has always been a low-key subject, not due to the fact that it is less challenging, but as it is the only specialty that doesn’t have much patient-interaction. Some don’t take up this specialty because they don’t want to lose touch with patients. On the other hand, a surgeon is looked at with awe and respect by the patients and he also walks away with all the glory, money, name and fame.

Anaesthesia is very important part of medicine as it is not possible to carry out any surgery without it. And today, if very ill and critical patients are getting operated, it is only because anaesthesia has become very safe with technological advancements. New drugs and equipment have made it possible to operate on patients, which was not possible 10 years ago.

How has anaesthesia evolved over the years?

Earlier anaesthesia was confined to operation theatres with an anaesthetist looking after the patient during the surgery. There was no role of an anaesthetist after the surgery. Now, they have a bigger role to play in post-operative care. With intensive care, came the concept of keeping a patient under the care of an anaesthetist, till the patient is out of danger or makes an improvement. So, improvement in after-care has brought anaesthesia to the forefront.

AIIMS has a screen clinic in OPD, wherein all patients who are supposed to undergo surgery are screened by anaesthesiologists. And whenever the surgeon thinks that a patient is problematic or has some other associated medical disease, then he is sent to the anaesthetist for consultation a week before or two. Hence, we are part of the preparation team where we work in tandem with surgical team.

Please brief me about the advancements in medical gases and equipment related to anaesthesia.

Presently, anaestehsia has moved beyond the realm of gases and vapours. Of course, they are still a part of the system in which one needs to make a person unconscious, pain-free and make not respond to any stimulus.

Modern anaesthesia is called balanced anaesthesia, in which one uses multiple specific agents for specific purpose. For instance, while one drug is given for relaxation, another for analgesic. It is important to note that anaesthesia is not just putting a patient to sleep, but looking after his entire body physiology while the patient is asleep.

In olden days, the drugs used were very long acting, taking as much as three to four days to get out of the body of the patient. The new drugs get out of patient’s body within minutes, enabling patients to go back home the same day. In yesteryears, if somebody was given ether he would have got up after few hours, but if somebody is given the new age halothane, he would get up after 15 minutes.

Modern anaesthesia machines are very safe. For instance, the machine will prevent one from delivering hypoxic mixture, and if the patients still develop that, the machine might just stop. New machines are also very precisely controlled, so that one can use very potent drugs with precise control.

However, unfortunately in our country we have no strict control over quality of medical equipment. There’s no regulatory mechanism in place in medical field. Even now machines without any safety devices are still being sold. There’s no regulatory mechanism in place in medical field. It is important to have audit systems to improve the condition. We should see to it that machines without safety devices are not sold as this will prevent even the inadvertent error.

What about further specialised courses in anaesthesia?

Although anaesthesia is a highly specialised work, it’s been realised that special group of patients need special care, especially patients with cardiac problems, brain surgery and children. These three specialties are coming up in a big way.

At AIIMS, recently we have started DM courses in cardiac anaesthesia and neuro-anaesthesia, with two seats for each specialty. Also, there are fellowship programmes in paediatric anaesthesia in our department, which range from three months to two years. For paediatric anaesthesia, there are no fixed number of seats, students come and get trained with us. Even for pain management, doctors come and get trained in pain clinics. We have three pain clinics at AIIMS, located at the main hospital, the cancer hospital and the neuro centre.

Should the procurement of anaesthesia equipment be the sole prerogative of the anaesthesiologist?

Ideally, it should be. However, in most government hospitals, it is a centralised mechanism and the actual user might not have much say. While buying a new equipment, one must look at two aspects: the availability of maintenance facility and availability of spares. Therefore, even if a less advanced machine is available, which can be serviced and its spares are available in India, then one should go for that. Service component is very important. There should be guidelines for standard equipment.

Please comment on the importance of interpersonal relationships between surgeons and anaesthesiologists.

Since any surgery is a team work, the interpersonal relationship is very important, especially the professional relationship. If anaesthetist and surgeons are helping each other and understanding each other’s problems, then it has a bearing on the patient outcome. Generally, in our country surgeons have an edge over anaesthesilogists and they tell the anaesthesiologist what is to be done and what should not be done. This is more common in private sector.

How do you see anaesthesiology developing 10 years down the line?

We have reached quite a reasonable stage and from now on, the growth and development will be slow paced. It will not be as fast as it has happened in the past 10 years or so. Of course, there’s lot to be learned. We still have to monitor unconsciousness and control that unconsciousness. We will see more and more development in post operative care and intensive care area. We will go more in pain management to reach a pain-free status.

Tell us about the programmes of Society of Anaesthesiologists.

It is a very old society, which organises conferences to enable scientific interaction and exchange of ideas. For the past couple of years, the Society has been organising CME programmes across the country with support from the World Federation of Societies of Anaesthesiologists (WFSA).

In a year, there are about six to eight CME programmes wherein we go to small remote areas with no facilities. Incidentally, I was instrumental in forging the tie up with WFSA in 1978-79 and since then, the programme is going on a regular basis. The main area of thrust of WFSA is to improve the standards of anaesthesia in developing countries.

We organise CMEs on pain management in Sri Lank, Thailand, Bangkok, Malaysia, Indonesia. Next year, we are planning programmes in Combodia, Vietnam and African region, where there are no facilities.

sapna.dogra@expressindia.com