Anesthesiologist: The silent force behind the scene

Abstract

The Anesthesiologist provides continuous medical care before, during, and after operation to permit the surgeons to perform surgeries; sometimes quite challenging that could otherwise cause substantial threats to the patient's survival. Anesthesiologists, because of their combination of skills are uniquely qualified to care for dying patients suffering from end diseases like cancer. These skills include knowledge of analgesic and sedative pharmacology for the management of pain, awareness of perceptual alterations along with well-known skills in drug titration and experience with critically ill and highly anxious, often agitated patients under stressful circumstances. Anesthesiologists are physicians who provide medical care to patients in a wide variety of situations. This includes preoperative evaluation, consultation with the surgical team, creation of a plan for the anesthesia (which is different in each patient), airway management, intraoperative life support, pain control, intraoperative stabilization of all the vitals, postoperative pain management. Outside the operating room, Anesthesiologist's spectrum of action includes with general emergencies, trauma, intensive care units, acute and chronic pain management. In spite of providing these highly skilled services, Anesthesiologists are facing a lot of stress these days which predisposes them to burnout, fatigue, substance abuse, and suicide. The practice of anesthesia in Indian scenario is different as compared to the western countries. In India, the Anesthesiologists are dependent on surgeons for their work. The degree of stress faced is due to a number of factors like the type and quality of work, his/her relationship with surgeons and the support he/she receives from colleagues and family.

INTRODUCTION

Anesthesiology is a specialized field of medicine practiced by highly trained doctors. It is defined by American Society of Anesthesiologists as "the practice of medicine dedicated to the relief of pain and total care of surgical patients before, during, and after surgery."[1] Anesthesiologist is a highly skilled specialist doctor who provides continuous medical care before, during, and after surgery to enable the patient to live a normal anatomical, physiological, pharmacological, and psychological life. Anesthesiologists are the Physicians specializing in perioperative care, development of anesthetic plan, and administration of anesthetics. Constant research in the field of anesthesia has led to marked reduction in anesthesia-related mortality and morbidity in spite the increase in challenging operations in pediatrics, adults, older, and sick population. To practice anesthesia, it needs dedication and hard work of approximately 12 years as compared to other nonmedical fields, and all this hard work is done for the benefit of society.[2]

DUTIES OF ANESTHESIOLOGIST

The Anesthesiologist is not only responsible for the anesthesia and overall medical management during surgery but also helps in optimizing the comorbid conditions of the patient for the safe outcome of the patient in the perioperative period.

With respect to such large responsibilities on the shoulder of Anesthesiologist, he/she not only functions as a person who administer anesthesia but also acts like a physician. That is why the name given to Anesthesiologist as a Physician Anesthesiologist or perioperative Physician is appropriate. It is said that “anesthesiologist is a physician to a surgeon and a surgeon to a physician.”

These days, role of Anesthesiologist extends beyond the operating room where he/she not only deals with complications of anesthesia postoperatively but also manages postoperative pain, chronic pain of cancer, labor analgesia, in cardiac and respiratory resuscitation, in blood transfusion therapies, respiratory therapies, etc. Hence, the Anesthesiologist has spread its wings beyond the four walls of operation theater. Following are the few duties carried out by the Anesthesiologist.

Preoperative evaluation

The aim of preoperative evaluation is to discover risk factors that may have an adverse impact on the safe conduct of anesthesia. Therefore, it is important that the Anesthesiologist must be provided with the true history of the patient and diagnostic tests. Preoperative evaluation also provides opportunity for the Anesthesiologist to interact with the patient and tell him/her about the outcome of the surgery and also reviews the risk and benefits of available treatment options without terrorizing the patient and makes him/her understand the importance of proper optimization and management of the risk factors. All this is called “informed consent” which should not be just a formality to take sign of the patient on a form or a file.

In India and other developing countries, sometimes Anesthesiologist is not made aware about the concurrent illnesses and medication status of the patient. Hence, the risk factors remain hidden. Many a times, diagnostic values are not true, ultimately leading to disaster on the table. Sometimes in order to get the case done, the patient is asked to hide the fasting status by the surgeons, which may ultimately lead to aspiration and then all the faults are made to fall over the Anesthesiologist. It is a common saying “never to tell lie to an advocate and doctor.” As per surgeon's point of view, they have their own problems with ever increasing lists of patients on every sitting, and they try to finish the list and do not want to postpone the patient.

Intraoperative management of patient

Physician Anesthesiologist uses advanced technology as required by minimum monitoring standards (MMS) to monitor the body's functions and determine how best to regulate body's vital organ system and treat any eventuality that occurs intraoperatively. These vital functions are heart rate and rhythm, breathing, blood pressure, body temperature, fluid, and electrolyte balance, and he/she also maintains a record of all the vital functions of the patient's body.

In India and in other developing countries, where anesthesia assistants are in shortage or not well-trained and in many hospitals which are not fully equipped with automatic monitoring devices, all the perioperative functions are manually monitored by the Anesthesiologist. It includes maintenance of intravenous lines at the appropriate site according to the type of surgery, preparing preanesthetic medication, and labeling them. He/she prepares emergency drugs and labels them, keeps ready intubation cart, does intubation, and then breathes the patient. Regional anesthesia whether spinal or epidural is administered by an Anesthesiologist because it is a highly technical job and requires skills and expertise which cannot be given by nonprofessionals. Most of the times, patients would not even realize that the Anesthesiologist is providing these critical services during surgery. All the stress is born by the Anesthesiologist to keep the patient safe and to keep the surgeon calm. This is the idea of our discussing this issue or, in other words, “silent force behind the scene.”

Anesthesiologists form an important member of the team performing fast track surgeries. Fast track surgery represents a multidisciplinary approach to improving perioperative efficiency by facilitating recovery after both minor that is, outpatient and major inpatient surgery procedures. It requires patient education and motivation, early feeding and mobilization, and a multimodal analgesic regime. The decision of the Anesthesiologist as a key perioperative physician is of critical care team in developing a successful fast track surgery program. By adopting fast track surgery technique, there is a significant reduction in the length of hospital stay without any increase in perioperative morbidity.[3]

Postanesthesia care unit

Role of Anesthesiologist in postanesthesia care unit or “recovery room” is even more important because after completion of surgery patient is still under the influence of some residual effects of the anesthetic agents and the Anesthesiologist has to watch the patient's activity level, adequacy of breath, circulation, level of consciousness, and oxygen saturation. Pain is optimized before sending the patient to ward or home or sometime to intensive care unit (ICU) if patient's outcome is not proper. Recovery room is the place where most of the casualties occur because in most of the hospitals/institutions, the recovery room is monitored by staff nurses or paramedical staff and is liable to be neglected. In the pre- and peri-operative period, patient is under the control of Anesthesiologist and the chances of error are negligible. Hence, recovery room is the place where Anesthesiologist should remain utmost vigilant.[1]

Pain clinic

This is an important field where Anesthesiologist has made its presence felt. More and more Anesthesiologists are focusing their attention in the specialty of pain management. Pain is to be managed not only in the postoperative period but other conditions such as intractable pain of cancer, pain of burns, herpetic neuralgias, low back pain, and diabetics neuropathies are also managed by Anesthesiologists directly. Almost all the units in government and private sectors have pain clinics where Anesthesiologist can do pain relieving procedures, counsel patients and their families, and can also give rehabilitative services to the patients having pain. Anesthesiologists also coordinate with other healthcare professionals who are working in pain clinics by forming multidisciplinary teams.[4,5]

Critical care unit

Anesthesiologists are uniquely qualified to give critical care services because of their extensive training in clinical physiology, pathology, pharmacology, and resuscitation. Some Anesthesiologists pursue advanced training in critical care medicine as ICU intensivists in both adult and pediatric hospitals. Being the incharge of ICUs, they direct the complete medical care for the sick patients. In ICU, Anesthesiologists as intensivists provide medical and diagnostic services, care of intubated or nonintubated patients, and also control the various types of infections besides coordinating with various other medical and paramedical personnel as the leader of the team.[6]

Role in trauma and disaster management

The disaster management is a new concept which is also being looked after by none other than an Anesthesiologist. Teams of doctors, which are meant for looking after disaster management, are usually headed by Anesthesiologists; because they are basically intensivists and are fully trained and expert in resuscitative measures. Though the concept is new, still many more things are to be done by the government agencies to handle the situations such as earthquakes, tsunamis, and terrorist attacks where mass casualties are there. In developed countries, disaster management is a separate and specialized branch.

Obstetric analgesia and anesthesia

In obstetric analgesia and anesthesia, Anesthesiologists work in the maternity unit to administer anesthesia to mothers for cesarean sections and prepare for painless normal deliveries (labor analgesia). Most of the labors and deliveries go smoothly but on some occasions when things go wrong, life of the mother and baby is at risk. In such patients, the presence of Anesthesiologist deals with two lives; one that of mother and another that of baby. Many a times, in the absence of pediatrician, an Anesthesiologist has to resuscitate the baby in addition to the patient undergoing lower segment cesarean section.

Burn unit

This is another aspect of working area of an Anesthesiologist where total care of patient; right from maintaining airway, circulation, and a fluid and electrolyte balance to managing pain of the patient is managed by the Anesthesiologist. In burn patients, very difficult situation arises when even intravenous access to the patient becomes difficult and here again Anesthesiologist is the person who accesses the intravenous lines by putting central venous lines. In some setups, there are hyperbaric oxygen units which are also monitored by the Anesthesiologists.

Anesthesia outside the operating room

As the medical technology advances, it becomes the need of the hour to involve the Anesthesiologist in caring for the patient during uncomfortable and prolonged procedures outside the traditional operational suites. The procedure includes radiological images such as computed tomography and magnetic resonance imaging in children, gastrointestinal endoscopy, placement and testing of cardiac pacemaker, defibrillation, lithotripsy, and electroconvulsive therapy. It would be impossible to perform many of these tests on infants and young children without the use of anesthesia and various sedation techniques provided by an Anesthesiologist.

Basic sciences and clinical research

Anesthesia research at the clinical and basic sciences level has been completed almost exclusively by Anesthesiologists with the goal of continuously improving patient care and safety. Research is conducted in each of specialties of pediatric, geriatrics, obstetrics, critical care, cardiovascular, neurosurgical, and ambulatory anesthesia.

Other areas of active study by the Anesthesiologist include transfusion therapies (blood transfusion and fluid therapy), infection control, and organ transplantation. The Anesthesiologists also do undergraduate and postgraduate teaching. They also supervise the trainees who are providing anesthetic services.

JOB AND LIFE SATISFACTION

Anesthesiologists are also reported to have high levels of job satisfaction, job challenge, work commitment and empowerment. Anesthesiologist has a long and successful career ahead, who is working with commitment is earning better than their counterpart in other specialties.[7] Junior Anesthesiologists being more active and young are easily employed and absorbed by the corporate sector. Even an independent Anesthesiologist who opts for freelancing is also earning fairly good monthly emoluments. In other specialties such as surgery, gynecology and obstetrics, orthopedics, eye, and ENT where a new postgraduate takes much longer time to settle after attaining various skills in the art of surgery, an Anesthesiologist settles very early in the job.[8]

Life satisfaction is arbitrary and average on account of good numerations they are getting but, on the whole, excessive workload contributes to a negative self-evaluation on quality of life besides hindering access to leisure activities whether in government job or in private set up.

STRESS IN ANESTHESIOLOGIST

The main cause seen for stress is lack of control of work environment, the unpredictability of work leading to high level of anxiety and overextension of work. Stress levels in Indian Anesthesiologists are more or less similar and universal as compared to their counterparts in the developed world. Due to ever increasing population ICUs are overloaded, nonavailability of trained staff, equipment and monitoring gadgets at district hospitals and peripheries, stress is increasing day by day on the Anesthesiologists to give up to mark care to the patients. Stress reaction is a basic physiological response to real or perceived danger which enables an individual to stand and fight or flee.[9] Anesthesiology is an area identified as being extremely stressful. Mean workload, an Anesthesiologist bears is elevated as compared to other professionals. The night shift in Anesthesiology changes sleep patterns. The atmosphere in the ICU is very gloomy where everybody is in stress, whether it is patient's attendants or staff. All this is reflected on us particularly when we see a patient dying before our eyes, whom we make every effort to save.[10]

When operation becomes successful, and patient goes to his/her home in a fine condition, all the credit is born by the surgeon. Anesthesiologist is seen nowhere in the picture. Even patient forgets the Anesthesiologist, who is the main person who gives a second life to the patient. The saddest issue is that if something unfortunate happens during the surgery which may be inevitable, all the discredit goes to the Anesthesiologist. In India, it is a common saying by a layman or even an operating surgeon that an overdose of anesthetic has probably been given, even if the faults might have been with the surgeon and the surgery itself.

Remarkably international studies of occupational stress and burnout in Anesthesiologist all have a similar outcome.[11,12] Imbalance between the demand at home and work, insufficient personal time, inadequate recognition, lesser reimbursement, fear of competition, job insecurity, social and professional isolation, litigation, and peer review were identified as stress factors. To cope up these stress factors, many Anesthesiologists adopt chemical abuse, alcoholism, and even may commit suicide.[13,14] Stress manifests itself as physical and emotional illness, absenteeism, poor performance, social withdrawal, substance abuse, and negative attitude.[15,16] There is high divorce rate and increasing number of single-parent families and other problems related to workload and stress in the Anesthesiologist. However, job satisfaction and good emoluments have temporarily reduced the stress-related problems in Anesthesiologists.[17] Parameters are there to obtain levels of his/her catecholamines released during the surgery and insult given by the increase in blood pressure to his/her vital organs. A study has been conducted on obtaining salivary cortisol levels during stressful conditions of Anesthesiologists.[18] They observed 12.5% endocrine reactions from 3781 samples. The mean cortisol increase amounted to 10.6 nmol/L (219%). A high proportion (71.3%) of endocrine reactions occurred without conscious perception of stress. Unawareness of stress was higher in intensive care nurses (75.1%) than in intermediate care nurses (51.8%, P < 0.01). Sources of stress can be environmental, interpersonal, and personal factors.

Physical assaults on doctors/anesthesiologists

Many times, Anesthesiologist has to face the wrath of the public, he or she is manhandled. People bring their patient in ICUs or in emergency in serious conditions and want that their patients should be hale and hearty after the treatment. In spite of the fact that attendants are very well-conveyed about the seriousness of the patient verbally as well as in writing, authorities and police remain mute spectator in such situations. The one major factor which comes into play is the nonpayment of hospital/ICU dues if mishaps have occurred.

Stress management

First of all, we have to recognize various causes of stress and sources from where stress is causing trouble to the Anesthesiologist. Then we look for various methods to resolve stress and these are:

• Discussing our problems with our colleagues on some platform like different societies, conferences, social network media like WhatsApps, etc

• Don't react immediately to any untoward situation unthoughtfully. Take time and then assert yourself

• Anesthesiologist should take proper rest, otherwise mishaps are liable to occur

• One can go on for yoga or meditation to relieve stress

• Getting personal indemnity done is also one of the methods to relieve stress in the form of legal and financial securities

• Avoid aggression[19]

• Nonchemical stress busters, avoid anesthetizing patients in stressful conditions, workplace which is understaffed or under equipped when under effects of alcohol or drugs and allurement of money

• Personal indemnity and insurance: To save oneself from litigation, Anesthesiologist has to get his/her personal indemnity and the premium for the personal indemnity for the Anesthesiologist is maximum out of all the specialties.

Future of Anesthesiology

In 1985, “the anesthesia patient safety foundation” was created, after that Anesthesiologist in India also started taking a keen interest in patient's safety. Many older techniques of anesthesia were rejected and new techniques were introduced, MMS were accepted as guidelines and new machines were introduced for the safety of the patient, with the result that mortality due to anesthesia has significantly reduced in India also. The contribution of Anesthesiologist resulting in improved medical care provided to the surgical patient is being widely recognized, and our role as intensivist is now being widely accepted. The Anesthesiologist will continue to enthusiastically share their unique perspective and expertise while serving as members of their medical staff. But at the grass root level, movements to impact legislative reforms and secure the advancement of anesthesia quality and patient safety, Anesthesiologists are yet not being involved, which is very important which if, as is heard that government is going to introduce nursing home act.

CONCLUSION

We, therefore, conclude by saying that an Anesthesiologist is a highly skilled professional and the most important member of the medical team for patient's safety and care. Although he/she is well-commuted to his/her job, job satisfaction is very high and they are highly paid, but excessive workload, odd working hours, nonappreciation by the surgeons and lack of awareness of their role by the society, inadequate sleep affect the quality of life of Anesthesiologist. With the result, he/she can have a negative lifestyle of living, but means of improving it, are always there. There is a great scope that services of an Anesthesiologist can be utilized to the greatest for the benefits of society which depends upon the attitude of the later as well as of surgeon.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.