The Person and the Procedure

At the beginning of anesthesia residency, we discussed three factors and how they influenced the morbidity and mortality of a surgery. What makes a surgery risky? Is it the patient and his comorbidities? Is it the surgery itself? Or is it the anesthesia? While of course it is difficult to tease all these factors apart, from what we can surmise, it is actually the stress of surgery that makes up most of the risk. Even though an appendectomy and a liver transplant both involve the same anesthetic technique, one is clearly a bigger procedure than the other. A knee surgery can be done under a spinal anesthetic or a general, but the difference in risk between the techniques is minuscule.

This is important to me because as the anesthesiologist, I am complicit in whatever we do, yet I bring the lowest risk to the table. There have been multiple times where I look at a patient or procedure and I worry. But most of the time, all we can do as anesthesiologists is to reduce the risk as best we can. We select more monitors, place better access, anticipate possible emergencies, and pre-emptively treat evolving clinical situations. This is the art of anesthesia.

I had to provide anesthesia for a middle aged man getting a tunneled dialysis line. This doesn't sound too bad until I realized that he had a cardiac arrest 9 days ago with pulseless electrical activity as well as congestive heart failure, atrial fibrillation, congestive hepatopathy, coronary artery disease, diabetes, and ascites. His cardiac arrest lead to acute renal failure, and now he is dialysis dependent. This is a scary anesthetic to provide; even though the procedure was minor and I would be administering as little as possible, the risk for something bad happening was very high.

Sometimes I feel that anesthesia is about tempering those dangers of surgery superimposed on a frail patient, and it is times like these that I feel I can utilize everything I've learned about medicine to use a gentle hand to guide a patient through a stressful situation.