New rubric – Suggested reading:
ESA members read papers which deal with professional and organisational aspects of our specialty. Our readers are kindly invited to contribute by sending their own recommendations.
In this issue we mention three articles about the impact of reducing residents work hours on patients’ management outcome, as well on their own well-being.
It would seem that the reduction of residents’ work hours in the USA to 80 per week did not have any positive effects on the physicians’ wellbeing and did not produce a decrease in the frequency of burnout syndrome.
The number of working hours for the European resident is now restricted to 48 hours weekly. Does it have any impact on the physician psychological condition? Good question……
Okie S. An elusive balance-residents’ work hours and the continuity of care. New Engl J Med 2007;356:26
Ahmed N et al. A systematic review of the effects of resident duty hour restriction in surgery. Ann Surg 2014;259:1041
Ripp JA et al. The impact of duty hours restrictions on job burnout in internal medicine residents. Acad Med 2015;90:494
Letter to the Editor
Ref: Editorial: A sleepy physician or a true partner (ESA Online Newsletter, issue 61)
Anaesthetist – Surgeon, partners who cannot divorce!
Nagappan Kumar | Cardiff Liver Unit, UK
It is true that great surgical advances have been possible by the sheer perseverance and hard work of dedicated surgeons. It should now be history to consider the surgeon as a technician. He/she should be considered an operating physician. This is especially true in subspecialties like cardiac and liver surgery. A good understanding of physiology is essential to achieve good outcomes in patients.
The success of liver surgery today could in a significant part be attributed to the understanding that the central venous pressure (CVP) should be kept low while the liver is resected. This single concept changed the operative mortality from 15 to 20% in the early 80s to less than 5% in modern liver surgical practice. This is only possible with close collaboration between the surgeon and the anaesthetist.
Although it is a fact that the surgeon gets the kudos for a good surgical outcome, this would not be possible without the entire team. This can perhaps be demonstrated in a personal experience I had with a patient. The liver resection was about to be complete and part of the tumour attached to the inferior vena cava (IVC) was going to be removed with a stapler. The stapler was fired. This did not go absolutely smoothly and I suspected that there may be a problem and compressed the IVC with my hand. When the stapler was removed we had a 5 cm linear defect in the IVC. I informed the anaesthetist, who noted no change in the patient’s parameters but was ready to act if need be. The crucial fact was that he did not panic and start giving fluids which would have made matters worse. The nurse was ready with clamps. There was no panic in theatre. We managed to clamp the IVC above and below the liver and along with a Pringle manouevre achieved vascular isolation. The IVC was sutured. This patient did not receive any blood transfusion and did not have any long term consequences. This is a good example of team work. The surgeon could not have achieved the result even if one member of the theatre team panicked and did something inappropriate.
We now operate on patients with many comorbidities and especially elderly patients. Many studies including our own experience has shown that the outcomes in patients over the age of 75 is as good as younger ones. This is due to the diligent preoperative assessment of the patient by the anaesthetist and optimisation of the physiology before the operation. Constant communication during surgery allows the anaesthetist to fine tune the physiology to enable safe surgery.
The role of the anaesthetist extends to the postoperative period as well. Pain relief which is crucial is achieved by expert placement and management of epidural analgesia in patients undergoing liver surgery. We have shown that the failure rates are low and it allows quicker recovery of patients following liver surgery. This was largely due to the placement of catheters by dedicated liver anaesthetists and management of the catheters and pain relief by a pain team led by an anaesthetist.
It is safe to say that in modern surgical practice the need for a good anaesthetist to choreograph the physiology of the patient is of paramount importance. The surgeon and the anaesthetists are partners who can never contemplate a divorce!