Annex A > Chapter 14 - Care in the Operating Theatre and the `Learning Curve' > Care in the operating theatre > The role of the anaesthetists
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The role of the anaesthetists
45 Dr Duncan Macrae also referred to the collaboration necessary in the operating theatre between the anaesthetists, the perfusionists and the surgeon:
`I think it [perfusion] is a shared responsibility between the perfusion technician, who is usually a scientist who has been trained to look after the circuitry and to understand the physiology of the heart-lung machine; but also it is a shared responsibility between that technician, the surgeon who is doing the plumbing side of things, putting the pipes in the appropriate blood vessels, and the anaesthetist who has overall responsibility for the physiology of the rest of the body whilst the heart is being looked at and operated on by the surgeons.
`So all three team members have a role to play in the overall conduct of perfusion. I think the most important thing about perfusion is that there is a proper structure and protocol in place, which all of those three elements will bind to. You asked me specifically about the role of the anaesthetist, and I think that that, in particular, is to help the perfusionist to interpret the blood gas levels, particularly the levels of oxygen and so on, in the blood during the bypass and the level of acid that builds up, and help him to manage that; to help the perfusionist to control blood pressure so it is not too low and not too high, because we know that in both of those situations that if there is a lot of blood coming back because the perfusion is not good, the surgeon may not be able to do the operation as quickly and as efficiently as possible. So there is that aspect of making the surgeon's job easier and also protecting the patient.
`So it is very much a team effort. If the surgeon has not put the pipes in or has put in a tube that is too small, the bypass may not be adequate. The perfusionist will say, "I cannot get enough flow". The anaesthetist will say that the oxygen levels are low or the acid levels are high.
`So all three must interact. It is not possible, for that category, to say really perfusion equals perfusionist; perfusion equals all three of those elements.' [58]
46 Dr Michael Scallan, consultant anaesthetist, commented further on the anaesthetist's role in the following exchange:
`Q. What is the responsibility of the anaesthetist if acidosis has occurred?
`A. There are two things. One is to try and prevent its development and that is to try and maintain an adequate perfusion, the need for circulatory arrest, the need for low flow may prevent that at a particular time. The other thing is to correct the acidosis when it develops, to give appropriate medication to reverse the acidosis.' [59]
`A lot of the work of perfusionists is dedicated to [the anaesthetist], but he will work with the anaesthetist and will discuss difficulties such as acidosis and what to do about it. The ultimate responsibility must be with the anaesthetist and with the surgeon.' [60]
48 Dr Scallan said that whether the perfusionist would make changes himself, for example, in order to correct acidosis, or wait for a prompt from the anaesthetist, would largely depend on the local arrangement. [61] Dr Underwood [62] commented that:
`In our department the perfusionists are fairly autonomous, although I agree with Dr Scallan they obviously work along with the anaesthetists in maintaining the perfusion of the patient during the operation.
`They also receive a lot of instruction from the surgeon who must have certain conditions in order to complete the operation, so that my perception is not that the perfusionist works for the anaesthetist in any sense, but would indeed work with the anaesthetist in many aspects.' [63]
49 Dr Peter Hutton was appointed as a Clinical Lecturer in the Department of Anaesthesia at the University of Bristol in 1982. This post carried honorary Senior Registrar status. He recalled that:
`... junior anaesthetists were well supervised by consultant anaesthetists. Towards the end of my training there were some non-bypass cases ... which I did alone but all paediatric bypass cases had a consultant present throughout or at least in the next theatre. All those cases which I did undertake "solo" were first discussed with a consultant who was always present in the hospital during the procedure.
`I cannot ever remember having any difficulty contacting consultants when they were on call or getting them in when appropriate.' [64]
50 Counsel to the Inquiry elicited the following information about the function of an anaesthetist from Dr Masey in the following exchange:
`A. In the anaesthetic room, when the child was brought into the anaesthetic room the child would be accompanied by a ward nurse and quite often by one or other or both parents. In the anaesthetic room would be a consultant anaesthetist, quite often a trainee anaesthetist and an anaesthetic assistant.
`Q. Okay. The patient would be anaesthetised?
`A. The patient would be anaesthetised.
`Q. And then taken to theatre?
`A. The patient would be taken into the operating theatre.
`A. Which is next door.' [65]
51 Dr Underwood commented in her oral evidence about the absence of the anaesthetist from the theatre during a period for which the patient is on bypass. She said:
`This is not ideal and in the climate of the time, meant a choice on the part of the anaesthetist between those patients upstairs [in the ITU] and downstairs [in the theatre]. On occasion, the ward round did not get done because the patient in theatre needed the anaesthetist, but it was more common, as I wrote in my statement, [66] to do the ward round at that time.' [67]
52 Dr Scallan was asked whether, in his experience, the choice was a common one for an anaesthetist, to have to choose between doing a ward round or seeing a patient who required attention in the ICU, and remaining in theatre during bypass. He replied:
`Yes, this dilemma did certainly arise. I have certainly experienced it myself. During the course of cardio pulmonary bypass it is undoubtedly a period when the demands on the anaesthetist are less, because a lot of the responsibility is dedicated to the perfusionist, and the anaesthetist does not leave the patient unattended; if the senior is not there, a junior anaesthetist would be present.' [68]
53 On this matter Dr Pryn said:
`I found it difficult and very stressful to look after sick patients on CICU [69] when I was at the same time anaesthetising for cardiac operations. Often I would have to leave my patient in theatre with a trainee anaesthetist while I went to CICU to assess patients. If I was the on call anaesthetist on a Monday, I would wait until my patient in theatre was safely established on cardiopulmonary bypass before visiting CICU for a complete ward round.' [70]
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Footnotes
[62] Dr Susan Underwood, consultant anaesthetist at the BRI since 1991
[64] INQ 0042 0002; letter to the Inquiry
[66] WIT 0318 0007 Dr Underwood
[69] Cardiac intensive care unit
[70] WIT 0341 0030 Dr Pryn