Handling and care of the patient: No. 11 (1944) Pt. 1 of 2

this is one of the many patients who go into operating theater every day from the moment that he is taken into the anesthetic room until he wakes in the ward it's up to all those who come into contact with him to take charge of his well-being the patient is frequently upset by neglect of small details of procedure which are less noticeable than the cler defects of anesthetic technique here collected together are many such errors fear has an important effect on the course of anesthesia many patients are nervous in spite of preoperative medication they should never be left alone without the reassuring presence of a nurse the unfamiliar apparatus in the anesthetic room is very likely to increase their fears quiet is an important factor any disturbance places an additional strain on the patient this anesthetic room is being used as a corridor and also as a store room for instruments needed Elsewhere on her return the nurse appears to have not the slightest interest in the case the anesthetist also has no time for even a few words with a patient these would have done much to reassure her the anesthetist begins now to check over his machine this should have been done before time is wasted changing cylinders and fetching instruments to the patient highly sensitive to noise and unable to see all that's going on these sounds are very alarming the doors of the anesthetic room have been left open and her growing fears are not relieved by the sight of a surgeon instructing his students in the finer points of his last operation again the anesthetic room appears to provide a convenient Corridor but the anesthetist is too busy filling his ether jar to pay any attention to such details a strong smell that spilt ether has now added to the patient's discomfort without washing his hands or glancing at the patient's chart the anesthetist begins induction the mask is put onto the patient's face with no warning almost immediately the nurse removes the blankets in order to cut the bandages to the semi conscious patient it appears that the operation is about to begin and she struggles violently at the first sign of movement the porter has rushed in he and the nurse fling themselves on The Wretched patient the anesthetist meanwhile loses control of the mask at last she is quiet but by this time everyone including the patient is warm and sweating while induction proceed ceeds to the satisfaction of the anesthetist the patient is left with her knees drawn up as anesthesia deepens her limbs relax her knees fall over sideways almost dragging her from the trolley to the ground in putting her back no one notices her arms slip out of the coverings and hang down over the edge of the trolley despite all these mishaps the anst makes no attempt to check the position of the patient on the trolley before going into the theater during the previous struggle her elbow was left sticking out over the side this catches against the door as they pass when the patient is in the theater her head falls back as she is lifted because the canvas of the stretcher doesn't come far enough up to support it fortunately the nurse notices the patient's arm in time to save it from being crushed against the edge of the table all this delay and the fact that the anesthetist has needlessly removed the mask means that the patient will now have reached very light anesthesia as you will have realized all the mistakes shown here were very simple and could have been avoided this is how it should have been done the patient is brought into the anesthetic room by a porter and a nurse from the Ward the nurse goes off to put on her gown and mask leaving the patient in the care of the anesthetic room nurse in hospitals where such staff is not available the porter must remain as on no account should the patient be left alone when the ward nurse returns she removes the patient's head Shaw and loosens the clothing around his throat if necessary she also Cuts any bandages around the neck everything is now ready for the anst on entering he closes the doors carefully behind him and says a few words to the patient a reassuring explanation of what is about to take place will gain his confidence and ensure his cooperation the anesthetist should make it a part of his routine to look at the chart and check the details of the patient's condition and of the premedication before beginning the induction he sniffs The Mask to make sure that the right anesthetic vapor is coming through and inspects the mouth for false or loose teeth at the same time the nurse can reassure the patient by holding his hand she keeps up a slight movement of her thumb if the hand is held motionless sensation becomes blunted and the feeling of reassurance is lost in the event of struggling the anist never loses control of the Mask if restraint has to be applied it should be just enough to prevent damage to the patient and to those around him and no more ideally two attendants should be present but when only one is available violent struggling should be restrained by catching the wrists holding the arms to the side and leaning across the trolley at the level of the patient's thighs drumming of the heels on the trolley may cause severe bruising unless it's quickly checked when induction has reached the stage of true surgical anesthesia the nurse may cut the bandages leaving the sterile dressing in place the cover ings are then put back the patient is now ready the anesthetist looks on either side to make sure that the patient is properly placed on the trolley and then gives the word to go into the theater on arrival at the side of the the table the anesthetist assures himself that the canvas comes up well under the patient's head he is then gently lifted onto the table the common position of the patient on the operating table is lying on the back with the arms placed along the sides and the head slightly raised on a flat pillow and turned a little to one side clenched hands may result in Gang Green so the fingers must be straightened and any ring should already have been removed before the hands are placed under the buttocks this is enough to keep the arms in position with the elbows close to the sides throughout the operation some an theists prefer to use cuffs fasten to the side of the table if the cffs are slack however the elbows May slip over the edge another method is to use a towel laid across the table under the patient the ends are brought around the forearms and hands and tucked in no matter what method is used to keep the patient's arms to his sides it is essential to see that they are secure if an arm should slip out during the course of the operation the muscular spiral nerve might be compressed between the humorus and the edge of the table and lead to paralysis alternatively the arms may be placed on the patient's chest either Crossing them over or placing the hands one on top of the other the the Gown is then turned back to enclose the arms and the ends are tucked under during anesthesia the normal heat regulating mechanisms are affected and warmth is essential in the care of the patient spare blankets should be placed on the warm pipes of the radiator ready for the return to the ward some hospitals are fitted with heated cupboards for this purpose the theater temperature should be at about 75° fah in abdominal operations or where there is a large area of body exposed the patient coverings also are important small rubber sheets should be used as large ones encourage fluid loss by sweating during the operation as much of the patient's body and limbs must be kept covered with light blankets or towels as is possible without impeding the surgeon a BAL man can lose a lot of heat from his head alone and the sh will do much to prevent this in most cases the patient's eyes close automatically during anesthesia if the eyes remain open the lids should be closed every few minutes to moisten the corner a great care must be taken to make certain that the eyes are shut every time the mask is removed or replaced rubbing the exposed eye with ether soaked Gau gives rise to that painful condition known as anesthetic eye in the same way make sure that the eyes are shut before putting on towels in deep and athesia when tear formation is reduced a drop of liquid paraffin may be instilled into the eyes to prevent dryness some anesthetists use this or a thick layer of sterile Vaseline in all cases the maintenance of a free Airway is an essential of anesthesia don't forget that apart from gross respiratory obstruction there may be minor hindrances to the breathing that can pass unnoticed until serious complications have set in here for example the anesthetist has realized that the breathing is unsatisfactory as shown by diminished movement of the rebreathing bag it may be due to a tired or a too eager assistant leaning on the patient's chest the use of a retractor under the liver or diaphragm May embarrass the breathing trauma in the region of the diaphragm is a contributory factor to the development of postoperative collapse of the lung the good assistant will not continue to exert pressure unless it's really helping in the performance of the operation the gradual accumulation of unwanted instruments on the patient's chest is an added burden the anesthetist should call attention to these and ask for them to be removed under anesthesia the vasor motor system cannot compensate for Sudden Change of posture any alteration of position must be done gently and smoothly and should be supervised by the anesthetist rough handling while putting on an abdominal binder may result in a serious fall in blood pressure this is particularly true at the end of a long operation e