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An operation involves many highly specialized people... Apart from
the nursing and technical staff, there are a number of specialist
physicians who may operate or assist, depending on the nature of the
surgical procedure that you are about to undergo.
The Anaesthesiologist Having an operation whilst being under anaesthetic is a very worrying and stressful situation for many patients. This brief overview of what being an anaesthetist entails should help to put those concerns to rest as well as give additional understanding as to what it is exactly that anaesthetists do. Anaesthetists are fully qualified doctors who have completed an additional five years of specialist training after their primary qualification. This additional training involves general and regional anaesthesiology, intensive care medicine, and pain management. Rigorous examinations must be passed at both the primary and final level. After this has been achieved, the candidate then receives a specialist qualification and is then eligible for registration as a specialist Anaesthesiologist with the Health Professions Council of South Africa. Scope of Practice: Patients that are scheduled to have surgery will be referred to a specialist anaesthetist for planning and implementation of their anaesthetic care. This entails optimization of the patient's condition, selection of an appropriate anaesthetic technique for that patient as well as suitable preparation of the operating theatre equipment. For many patients the choice will be either "general anaesthetic" where the patient is "put to sleep" or "regional anaesthetic" such as a spinal or epidural block. These options are usually carefully explained to the patient prior to their anaesthetic. When emergency operations are undertaken for trauma or acute surgical illness, the anaesthetist's special skills in resuscitation and advanced life support are called upon. In their wider role, anaesthetists have been called peri-operative physicians because they provide care throughout the peri-operative period. This period can be divided into three parts:
YOU AND YOUR ANAESTHETIC So, you are scheduled to undergo surgery. We hope that the following pages will help answer any questions that you may have and alleviate any fears. We have tried, as far as possible, to write this section in "layman's terms". Please remember that these are only generalized guidelines. If any of your questions still go unanswered, please feel free to discuss them with your attending anaesthetist. Alternatively, you could contact us here.
HOSPITAL ADMISSION Prior to your surgery, you will be admitted to a hospital or day clinic. This admission process will include an administrative aspect (the hospital will need to take down all your details including name and address, contact persons and medical aid details) as well as a nursing aspect (taking your medical history and preparing you for the surgery). This can all be a time consuming process and you should ensure that you arrive at the hospital timeously. As an alternative, most modern hospitals offer a "pre-admission" facility where most of the paper work can be completed days or weeks in advance and the admission on the day of surgery is much smoother and less rushed. Please ask your surgeon if your hospital has such a facility and make use of it. It really makes the day of your surgery far less stressful. Some medical aids are reluctant to permit admission to hospital the night before major surgery. For minor procedures in a healthy patient, this is usually not a problem. However, if you are having a major surgical procedure or you have serious medical problems, it would be in your interest to be admitted to hospital the day before surgery. Should your surgeon or anaesthetist recommend that you be admitted the day before surgery and your medical aid refuses you this right, we would recommend that you insist that they supply you with written confirmation that they accept responsibility for this decision. Most medical aids require patients to obtain a pre-authorization number before any surgical procedure. Please remember that you should do this well in advance, as the lack of this number can lead to delays in your admission and surgery. Also, please remember to bring your medical aid card and identity document to the hospital with you. For more information on the "do's and don'ts" before surgery, please click on the Pre-op guidelines link on our home page. PRE-OPERATIVE VISIT AND PREMEDICATION All patients undergoing surgery should be seen by the anaesthetist prior to surgery. The pre-operative visit will entail the anaesthetist taking your medical history. This will normally include previous anaesthetics and any complications and side effects, your current and past medication and any relevant medical history. If you are taking any medication whatsoever, please bring a list of these drugs with you to the hospital. There are literally thousands of "little blue blood pressure pills" and it is vitally important for the anaesthetist to know exactly what you are taking. Also remember that "herbal" or "natural" medications can have an affect on your anaesthetic and these should also be mentioned to the anaesthetist. Alcohol and tobacco use are also important factors. Your anaesthetist will not judge you if you drink or smoke (or use "recreational drugs"), but it is extremely important for him or her to know about these in order to administer a safe and appropriate anaesthetic. Following the history, the anaesthetist will then examine you. In healthy patients, this process may only take a few minutes. However, in medically complicated cases presenting for major surgery, this process may take up to an hour. The next time you see your anaesthetist, you will be in theatre. So now is the time to ask any questions you may have. Remember, the only stupid question is the one you don't ask! Ideally, we would like to see all our patients in the ward before they go to theatre. However, please bear in mind that for a theatre list starting at 7.30 in the morning, the anaesthetist needs to be in the theatre by 7.00 to prepare the equipment and do a whole series of safety checks. Once the list has started, the anaesthetist is unable to leave the theatre as he / she is constantly monitoring other patients. If you have a late admission to the ward, you will then only be seen by the anaesthetist once you are transported to the theatre. Patients often find it frustrating to be admitted to the ward at 6 o'clock in the morning if they are only due for surgery much later in the day. Please bear in mind that this is done for your own safety. Finally, in some patients, a "pre-med" is prescribed. This is normally a drug that calms the patient and reduces anxiety. For young healthy patients undergoing short procedures on a day-patient basis, this is often omitted as patients are usually eager to be discharged as soon as possible. If, however, you are at all anxious about your surgery, please ask your anaesthetist to prescribe a pre-med. It is important to remember that these drugs take about 90 minutes to take effect and can only be prescribed if the anaesthetist has seen you in the ward. So the bottom line ….. get admitted as early as possible if you require a pre-med. CHILDREN AND ANAESTHESIA Anaesthesia for children can be a very traumatic situation, not only for the little patient, but also for the anguished parents. Please remember that a child undergoing an anaesthetic is nothing strange. Experienced anaesthetists may literally anaesthetize hundreds of children every month. While it may be something terrifying for the family, it is an everyday occurrence for the anaesthetist. Be honest with your little one. Explain to them what is going to happen. Don't mislead them by saying that it "won't be sore" after the surgery. It is far more important to tell them that they may have some discomfort after the operation, but that they will be given more than enough medicine for the pain. It is very important to make them feel comfortable in the hospital. Bring along a favourite toy. Most hospitals are quite happy for one of the parents to accompany the child into the theatre while the anaesthetic is administered. Please discuss this with the hospital and the anaesthetist. Most children are anaesthetized with gas. A small mask is placed over the child's face. It takes a while for them to go to sleep, and just before they do so, they may go through a phase where they wriggle around on the theatre bed. Do not be alarmed by this. It is quite normal, they are not suffering at all and they don't remember this. Rules for being without food and drink are slightly different in children. Please check our Pre-op guidelines link for more information. TRANSFER TO THE OPERATING THEATRE You have now been through the process of admission to the hospital and the ward routine and you are ready to be transferred to the operating room. In most hospitals, you will be accompanied by a porter and a nursing staff member from your ward. Upon arrival in the operating suite, you will be met by a member of the recovery room staff. This staff member, along with the ward staff, will verify your personal information. They will confirm with you the nature of your surgery and, in the case of limb surgery, whether it is to be performed on the left or the right. Do not be alarmed by this. It is merely a system of checks and double checks to ensure your safety IN THE THEATRE Welcome to the theatre!!! This is where we, as anaesthesiologists spend our days …. and often our nights. To you, it may be a foreboding place. To us, it is merely our place of work just like your office. You may be surprised to see so many people in the room, but rest assured that each member of the team is there to look after you. Apart from the anaesthetist, there will be an anaesthetic nurse. This is a specially trained member of the nursing staff whose sole role it is to assist the anaesthetist. The "scrub" sister is a highly qualified person who helps the surgeon by preparing all the necessary instruments and having them on hand. By the time you enter the theatre, she will often be "scrubbed" and wearing her gown, gloves, mask and cap. Assisting the "scrub" sister is the "floor nurse" whose job it is to fetch any additional equipment the surgical team might require. Finally, in certain types of surgery, a technician may also be present in the theatre. The anaesthesia team will now prepare you for your anaesthetic. MONITORING DURING THE ANAESTHETIC By the time you arrive in the theatre, the anaesthetist and his / her nurse will have already spent a great deal of time checking and double checking all the equipment. Throughout your anaesthetic, the anaesthetists will never leave your side. He / she is constantly monitoring your vitals signs every few minutes and these are recorded on the anaesthesia case record. The anaesthesia team will now connect you to various monitors. These are absolutely routine and are nothing to be alarmed about. Three (sometimes five) stickers will be placed on your chest. These are connected to the ECG machine which will be used to monitor your heart during the anaesthetic. A blood pressure cuff will be placed on one of your limbs and a small peg called a pulse oximeter placed on a finger. This clever little machine measures the oxygen concentration in your blood stream. Once you are asleep, a multitude of other monitors may be used. These include capnography, LOC (level of consciousness) monitors, temperature monitors and various forms of "invasive" monitoring. All these bits of machinery are there to ensure your safety. RECOVERY ROOM AND THE POST-OPERATIVE PHASE Once the surgery is completed, you will be transferred to the recovery room. Here your anaesthetist will hand you over to a member of the nursing staff who is specifically trained to manage patients recovering from anaesthesia. The intensive monitoring you enjoyed in the theatre will be continued in the recovery room. Once you are physically awake and able to meet certain criteria, the recovery room sister will consult with the anaesthetist who will then authorize your discharge from the operating suite back to your ward. PAIN MANAGEMENT Most forms of surgery are associated with some form of discomfort. Your anaesthetist is the best qualified person to help you in controlling this pain. Please click on the pain management link for more information on this important issue. PAIN MANAGEMENT AFTER SURGERY Most surgery is associated with some degree of post-operative discomfort. Your anaesthesiologist is the most suitably qualified person to advise you on the various methods available to control your pain. Please click on one of the links below to access more information: HOW MUCH PAIN WILL I HAVE? WHAT METHODS ARE USED TO CONTROL PAIN? IS ADDICTION AN ISSUE? PAIN LINKS HOW MUCH PAIN WILL I HAVE? Most surgery is associated with some degree of post-operative discomfort. Your anaesthesiologist is the most suitably qualified person to advise you on the various methods available to control your pain. Please feel free to discuss this important issue with him / her. The amount of pain is affected by numerous factors. These include:
Minimally invasive surgery (or "key-hole surgery") is gaining in popularity and is associated with less pain, quicker recovery and often earlier discharge from hospital. Your surgeon will be able to advise you on this matter. Patients are often led to believe that taking "herbal" or "natural" preparations will decrease the level of post-operative pain. Do not heed this advice. Many of these preparations, including arnica, st. John's wort and preparations containing garlic and ginger may greatly increase the risk of post-operative bleeding and should be discontinued 10-14 days prior to surgery. Even though you may not regard them as "medicines", it is extremely important to let your anaesthesiologist know if you have been taking any of these remedies. With currently available technology and pharmacological advances, there is no reason why any patient should suffer unnecessary pain following surgery. METHODS AVAILABLE TO CONTROL YOUR PAIN The anaesthesiologist is armed with a vast array of methods to control post-operative pain. These range from the administration of systemic analgesics (painkillers) to the performance of various forms of regional anaesthesia. Regional anaesthesia involves the science of injecting local anaesthetics around the nerves which supply the area upon which surgery is to be performed, thus "numbing" the area. This website cannot contain detailed descriptions of all these methods. It is the right of our patients to discuss the pro's and con's of each with the anaesthesiologist prior to surgery.
IS ADDICTION AN ISSUE? In the past, many patients have been hesitant to accept pain killers because of a fear of "addiction". The good news is that numerous well-conducted international studies have proved that without any doubt, the use of pain killers in the acute post-operative phase does not lead to addiction. Post-operative pain should normally disappear after approximately 8 weeks. If you find that you are still suffering from pain 3 months after surgery, the possibility exists that you are suffering from what is referred to as chronic pain. In this situation, you should not still be using normal pain killers. You should then contact a unit that specializes in the management of chronic pain. REGIONAL ANAESTHESIA Regional anaesthesia is the science of injecting local anaesthetic drugs around the nerves that supply sensation to the area of your surgery. This is referred to as a "nerve block". Nerve blocks can be performed as the sole form of analgesia (in other words, the "block" is performed with the patient awake and provides sufficient pain relief for the surgery to be performed with the patient awake) or as supplemental analgesia (the patient is given a general anaesthetic for the surgery and the "block" is performed purely for post operative pain relief). Please click on one of the links below to access more information on various forms of regional anaesthesia:
EPIDURALS Epidural anaesthesia involves the placement of a needle between two of the vertebrae of the spine to reach the so-called "epidural space". This is the area just outside of the fibrous sac that surrounds the spinal chord. All the nerve roots leaving the spinal chord pass through this space, and by injecting local anaesthetic drugs into this space, the anaesthesiologist can "numb" certain areas of the body. Often, an epidural catheter (a very tiny plastic tube) is placed through the needle before the needle is removed. This catheter enables us to keep the epidural working for as long as it is needed. Although it sounds fairly daunting, an epidural is generally a painless procedure as the skin is anaesthetized with local anaesthetic prior to the epidural injection. Patients are normally only aware of some pressure on the spine. Epidurals can be performed with the patient either awake or asleep. Epidurals are widely used for:
SPINALS Spinal anaesthesia involves the placement of a small needle between two of the vertebrae of the spine to reach the so-called "spinal space". This is the area inside the fibrous sac that surrounds the spinal chord and it is filled with fluid. By injecting local anaesthetic drugs into this fluid, the anaesthesiologist can "numb" certain areas of the body. This usually leads to muscle weakness in the area anaesthetized. However, this weakness is temporary and normal muscle strength returns as soon as the spinal wears off after a few hours. As is the case with epidurals, spinals are generally painless procedures as the skin is anaesthetized with local anaesthetic prior to the spinal injection. Patients are normally only aware of some pressure on the spine. Spinals can be performed with the patient either awake or asleep and are often used as the only form of anaesthetic so that the patient can be awake during the surgical procedure. Epidurals are widely used for:
PERIPHERAL NERVE BLOCKS Peripheral nerve blocks are the latest and fastest growing form of regional anaesthesia. Here, local anaesthetic is injected around specific nerves that supply the sensation to various body regions. Unlike spinals and epidurals (where the numbness is usually experienced on both sides of the body), peripheral nerve blocks are normally one-sided and "more focussed" on the area of surgery. To find the nerve, the needle is connected to a device known as a nerve locator which sends tiny electrical impulses enabling the anaesthesiologist to accurately find the nerve. There are a vast number of uses for peripheral nerve blocks. For example, a sciatic nerve block gives excellent pain relief for ankle surgery while an interscalene block enables patients to undergo effective physiotherapy following shoulder surgery. Although used most commonly in orthopaedic surgery, certain forms of peripheral nerve blocks are extremely useful in breast surgery and surgery of the head and neck. P.C.A. "PCA" stands for patient controlled analgesia. Following surgery, the patient is connect to a P.C.A machine. This piece of equipment constantly provides the patient with a sustained level of pain relief. However, what makes P.C.A. unique is that the machine has a push button. When pressed by the patient, this push button asks the machine to give the patient an additional dose of pain killer. This leaves the patient truly in control of his/her own pain treatment. There is no need to ask nursing staff to administer pain medication. The P.C.A. machines are individually programmed by the anaesthesiologist in theatre. This programme includes certain safety mechanisms so that it is virtually impossible for the patient to administers "too much" medication. The controls of the P.C.A. machine are also locked electronically by the anaesthesiologist so that the settings cannot be changed by anyone else. SYSTEMIC ANALGESIA Systemic analgesics are any pain killing drugs administered by intravenous methods, intramuscularly, subcutaneously (under the skin), rectally or by mouth. Drugs that are commonly used include morphine, tramadol, pethidine, paracetamol, aspirin, codeine, anti-inflammatories and numerous others. For acute pain, morphine still remains the most trusted drug on the market. Many patients believe they are "allergic to morphine". However, what they have experienced in the past is not an allergy, but normal side effects of morphine. These include itching, nausea, constipation and vomiting. A number of drugs are available to counteract these side effects and these can be prescribed for you by your anaesthesiologist. If, however, you have experienced any difficulty in breathing following the administration of morphine or any of its derivatives, please tell your anaesthesiologist. PRE-OPERATIVE GUIDELINES What should I do before my surgery? Before being admitted to hospital for surgery it is important to ensure that there are no medical conditions or other factors which may put you at unnecessary risk from the procedure, or cause your operation to be delayed or cancelled. On admission you will be assessed firstly on your medical history and later by the anaesthesiologist; it is crucial for your safety that you give accurate information about your pre-existing medical conditions, your medications, whether or not you are a smoker and how long since you last ate or drank. If your surgery is urgent then while there may not be time to implement the suggestions below, it remains important for the anaesthesiologist to have the information needed. Existing medical conditions:
New medical conditions: Intercurrent illnesses such as colds, flu, bronchitis and pneumonia may markedly increase your risk of complications under anaesthesia, and you should not undergo elective surgery while you have an active infection. Please be sure to attend your regular physician or check with us if you are unsure. Smoking: Smokers are at increased risk of complications following anaesthesia and surgery. These result from both the short-term effects (airway irritability, decreased ability to clear sputum from the chest) and the long-term effects (lung tissue destruction, emphysema and heart disease). You can reduce the risk of complications by stopping smoking. Even twenty-four hours of not smoking will reduce your risk of hypoxic (low blood oxygen) events; however you need to stop 6 to 8 weeks before surgery for the benefits to be substantial. Also you do not want to be suffering symptoms of enforced withdrawal at the same time as you are recovering from major surgery. Starvation guidelines: You will be warned by your surgeon not to eat or drink before your surgery. This is important! It is extremely dangerous to disregard this or to conceal from your anaesthesiologist that you have eaten. Why is this? Anaesthesia relaxes the functional valve system preventing regurgitation of stomach contents into the throat; if there is food residue in your stomach this may enter your lungs leading to major damage and even death. The following guidelines should only be disregarded in the case of emergency surgery: Adults: Do not eat within 6 hours of your anaesthetic.It is preferable not to eat on the day of your surgery even when this is scheduled for the afternoon unless you have been given specific permission to do so. Note: This does not mean that you cannot take your medications. If you are taking anti-hypertensives, anti-anginal drugs or anti-epileptics these should be taken with a small amount of water (25 ml) 2 hours before your surgery. If your surgery is scheduled later you may drink water or clear fluids (apple juice, black tea or coffee, coke etc) up to two hours before the anaesthetic. Children: Children become distressed when hungry or thirsty and should not be starved unnecessarily. The following are safe but should not be reduced:
Fees: Your Medical Aid may reimburse you the full amount of the doctors fee or only a part thereof, depending on which Medical Aid and which Plan you have. You should be sure before entering the hospital whether your Medical Aid will cover the doctors fees or whether you will have to make up any difference. Proper preparation for your surgery may make all the difference. It is much preferable to contact us at the numbers given on this website if you are in any doubt. We wish you a safe and speedy recovery from your surgery. ANAESTHETIC FEE STRUCTURE The fees that anaesthesiologists charge are a summation of the preoperative consultation and a time based anaesthetic procedure fee. The consultation is needed to assess any patient risk factors and to enable planning of the anaesthetic management. The consultation fee makes up a significant percentage of our total anaesthetic fee and while this often seems inappropriate for patients the reasons are:
If your procedure is either unbooked prior to the start of the list or an emergency then this type of case attracts an additional 'emergency fee' irrespective of the time of day. If the attending anaesthesiologist needs to make a special trip to the venue were your procedure is booked this will attract an additional 'emergency travel' fee. These fees are included to remunerate anaesthesiologists for the disruption to their planned workday and to encourage timeous attendance at any emergency. The Department of Health in conjunction with the Council of Medical Schemes has developed unilaterally a National Reference Price List (NRPL) to remunerate medical professionals. Medical Schemes or Funders then decide what remuneration rate they will use. These can be 100%, 150% or 300% of the NRPL rate. In Durban a significant portion of the Medical Funders offer on some of their packages a 300% reimbursement cover for in-hospital treatment. Medical aid should be viewed as an insurance cover and the type of package one chooses will dictate what one's excess will be. For example some medical aids offer a plan to cover our entire fee, whilst other plans only cover a small proportion. The choice is yours the consumer and it is important to remember that we contract with you the patient and not the Medical Funder. We offer a preadmission consultation service for those high-risk cases that need investigations and medical management prior to the elective surgical procedure. This service has reduced the risk of cancellation of your booked procedure due to being medically unfit for an anaesthetic. We also offer and manage an acute pain and chronic pain service. As it is often difficult to discuss finances with your anaesthesiologists in a busy general ward it is recommended that you contact our rooms and discuss any financial concerns prior to the booked elective surgical procedure. |