Anaesthesiology in India: Remarkable unity in a vast diversity.….

“Punjab, Sindh, Gujarat, Maratha

Dravida Utkala Banga”

- Rabindranath Tagore

How aptly do these lines describe the diversity of our country! India has a diverse culture, variable topography, numerous religions and sects but still 'Unity in Diversity' is one of India's most powerful characteristics. Would we not be right in extrapolating this to our speciality and saying that 'Unity in Diversity' exists in anaesthesiology too in our nation? India's diverse culture started off with the Indus valley civilisation, whereas anaesthesiology started off scientifically with the administration of wine and ether. Both, thus, have a definite birth. From this, to the world of anaesthesia today, several diverse techniques peacefully co-exist, some as simple as intravenous hypnotic injections and some as complex as microdialysis catheters to know the internal milieu of the brain. The subject is fast expanding with widening horizons and enhancing scope both in clinical practice and in research. We may be a little biased in saying but if a subject can be exceptionally useful, meticulous, exciting, paying, least expensive yet diverse, then it has to be anaesthesiology of course! Anaesthesiology, as a discipline in our country has progressed steadily and ultrafast in the last three decades. From the North (Kashmir, Uttar Pradesh, Uttaranchal and Punjab) where the pure waters of the Ganga, Saraswati and Sindhu flow, up to the South (Kanyakumari) where the vast ocean washes her southern shores, India has an infinite diversity. Similarly, this diversity is exemplified in the various sub-specialities and super speciality courses in anaesthesia that have developed over time and are now well-established in our country [Figure 1]. Bringing them together at national level is one parent body, the Indian Society of Anaesthesiologists (ISA) which itself exemplifies the remarkable unity in a vast diversity. The ISA has approximately 32,000 registered members at present and most probably 15 to 20 thousand non-registered practising anaesthesiologists in India, at the moment. There is diversity in the distribution of qualified anaesthesiologists too, in our country, with rural areas having a deep scarcity of anaesthesiologists.

Figure 1.

Depicting imaginative comparison of our Anaesthesiology speciality to our nation's geopolitical structure

Indian cuisine, religions, politicians, languages, culture, beliefs, practices and attire all reflect diversity. Similarly, the varied drugs, instruments, machines, techniques, work set-ups, guidelines and work practices reflect the rich diversity of our subject. Newer machines, newer instruments, newer drugs and newer monitoring techniques are coming up. Thought, orientation, physical ability, practice and leadership qualities amongst anaesthesiologists are also variable. We have to address the anaesthesia needs of a diverse category of surgeons and an even more diverse patient population. A recent survey of work practices amongst anaesthesiologists in India showed that there is a disparity in anaesthesia services provided in different areas of our country due to varying protocols and set-ups. The disparity was regarding practices involving pre-anaesthetic check-up, checklist compliance, intraoperative record-keeping, type of breathing circuits used and assistance by operation room assistants.[1]

An apt example of diversity in anaesthesia day to day practice would be the variable methods adopted for the assessment of intraoperative nerve blockade. Some anaesthesiologists use signs like vasodilatation in the area of the nerve or plexus, heaviness in the area and patient's reports of sensations in the area meant to be blocked, while some test for light touch to cotton wool, for pain by pin-prick or movement of the painful joint, for cold sensation loss by use of ethyl chloride or ice, and still others test for associated motor blockade. Others use electrical stimulation, increase in skin temperature, measures of perfusion or flow indices derived from the pulse oximeter, heart-rate variability, analgesia-nociceptive index, cardiorespiratory coherence index, electroencephalography changes, biomarkers and imaging techniques.[2]

This issue of the Northern Supplement of the Indian Journal of Anaesthesia (IJA) is the beginning of a new era in Indian anaesthesiology academics and it aptly exemplifies this peaceful diversity in our subject. It opens with a randomised controlled trial (RCT) on subarachnoid block for lower limb surgeries.[3] A diverse array of studies soon follow with an interesting RCT on bispectral index guided induction of general anaesthesia using etomidate and propofol,[4] and a comparative study of a video endoscope with established video laryngoscopes and the standard 'Macintosh laryngoscope'.[5] A RCT to evaluate the effect of quadratus lumborum block on opioid sparing effects[6] and a case series on the effect of intraoperative intravenous lignocaine infusion on the haemodynamic stability and postoperative recovery following intracranial aneurysm surgery[7] add to the diversity of research articles presented in this issue.

Airway assessment is another issue with different methods complicating it. The existence of diagnostic diversity is symbolised by a wide spectrum of airway assessment tests, scores and tools to identify the patient with the difficult airway preoperatively-the Mallampati test, modified Mallampati test, various distances, the Wilson risk score, upper lip bite test, mouth opening test, El-Ganzouri multivariate risk index, radiographical assessments of the head and neck including X-ray, computed tomography and magnetic resonance imaging, virtual endoscopy and ultrasonographic assessment of the airway. In spite of all this it is believed that airway assessment has yet to really come of age.[8] Many clinical trials currently focus on the effectiveness of a single anatomic predictor in predicting difficulty. Efforts to develop multifactorial tools which will successfully predict difficulty with airway management are going on.[8] This supplement of the IJA has an interesting study which aimed to evaluate and compare three different ultrasonographic calculation methods for tongue volume in real time 2D ultrasonography and correlate with Modified Cormack-Lehane grading observed under direct laryngoscopy. The study concludes that all three methods to calculate tongue volume were equally good to assess difficult laryngoscopy.[9]

There is a wide diversity in the airway management techniques too. A recent survey was conducted on current difficult airway management practice. During the assessment of the level of comfort of practising anaesthesiologists with diverse airway equipment, there was a diversity of answers from the respondents; but the most frequent technique preferred for anticipated difficult intubation was video laryngoscopy and for unanticipated difficult intubation when conventional techniques failed, a supraglottic airway device was used.[10] In spite of all the efforts for identification, the difficult airway may still be unpredictable to some extent. This is because it is influenced by many subjective factors including the clinical setting and the skills of the airway proceduralist. Both the clinical settings and the skills can be diverse as the type of airway devices available may depend on the clinical setting. A study in this supplement evaluates the combination of an endoscope (a 5mm external diameter, 30° lateral illumination laparoscope) used in conjunction with the Macintosh laryngoscope. The study concludes that the performance of this video endoscope is comparable to C-MAC D Blade and superior to Truview EVO2 and Macintosh laryngoscope with respect to the intubation difficulty scale score and thereby it may provide an effective alternative to commercial video laryngoscopes in low resource settings.[5] Despite of our current knowledge and skills, airway emergencies can still occur, whether anticipated or unanticipated. The diverse situations of airway emergencies and their management are other areas of interest and we have an informative narrative review on this topic adorn this supplement. In this review, the authors have described the aetiology, evaluation and management of airway emergencies. The review concludes that early recognition of a threatened airway and maintaining oxygenation are very important in managing airway emergencies.[11]

This era is full of competition with relentless pressures-the pressure of clinical work, administrative work, family commitments and coronavirus disease-19 (COVID-19) work. It is really amazing that in spite of all this, our anaesthesiologists have not got bogged down and are doing good research work and maintaining academic momentum during COVID times.[12,13] Each article and page of this issue depicts the diversity of our subject. I am sure that these studies designed methodically, conducted with scientific accuracy, presented in a scientific style and laced with a generous bounty of scientific references, will definitely live up to the academic taste of the readers.

To be born as an Indian is a boon indeed. To adorn anaesthesiology as a profession is an even greater boon. Those who take up this branch do not have to struggle much to get jobs after completion of their post graduation. They get immediate employment in intensive care units, can go into private practice or can join teaching institutes. In the yester years, we had to prove to the world our importance; but today things have changed. COVID has informed the nation and the world about our importance and our guidelines are being highlighted at the world stage.[14]

Our subject has diversity in its many pages, and it is fast-growing. There are an infinite number of pages which remain yet to be unfolded. A lot of good research is yet to be done and newer clinical applications are yet to come in. As Swami Vivekananda had said 'We stand in the present, but open ourselves to the infinite future.' One thing that unites us in all aspects of this diversity is the inclination to practise safe anaesthesia. India has proved time and again that diversity does not pull people apart; instead it brings them closer together and has become a role model for others to follow. Recently, ISA too has asked our fellow anaesthesiologists to remain united not only during COVID times but against all diverse and adverse situations.

So, come, let us remain united and safely practice anaesthesia in this diversity –in a diverse subject called 'Anaesthesia' and in our diverse country called 'Bharat'.