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Scott Weingart
Bringing Upstairs Care, Downstairs
Bringing Upstairs Care, Downstairs

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by Malcolm Fisher (World Medicine October 1976)

Surgeons and anaesthetist have a curious sadomasochistic
Roland and Oliver, Laurel and Hardy, Tristan and Isolde, Lillee and
Thompson have been dissected, analysed and lauded. The equally
temptuous relationship between surgeon and anaesthetist is less
lauded, and sometimes less laudable.

The love-hate aspects of the relationship are governed by two
historical truths: without surgeons, anaesthetists would be
(hence the diversification into intensive care, pain clinics,
hyperalimentation, and the like), and, because all surgical progress
has been made possible by anaesthesia, without anaesthetists, most
patients would rather keep their gallbladders, prepuces, and ugly

As surgery has progressed and become more horrendous the function of
the anaesthetist has changed from providing good operating conditions
for the surgeon to saving the patient from the surgeon. As one cynic
put it: "They will do brain transplant one day, just as soon as I can
work out which bit to wake up".

I got my first insight into this unique relationship when I changed
from being a surgical resident to being an anaesthetic resident. On
first day I learned the basics from someone who, while unknown in
scientific circles, is regarded highly in the antipodes as an
anaesthetic philosopher. In my first five minutes he taught me the
three fundamentals of anaesthesia.

* "Always check the oxygen supply."
* "Always identify the patient and the operation."
* "Hate all surgeons and hate the slow bastards most."

I was a little taken aback but I soon learnt that these rules, like
many other things he told me, were essential for survival. On my
second day, he initiated me into the inner circle which knows the
Cook's three laws of surgery:

* Surgery begets surgery.
* The adjustment of an operating light is an immediate signal for
the surgeon to place his head at the focal point.
* No substance is more opaque than a surgeon's head.

After three weeks I believed I had anaesthesia mastered, much so that
I asked a surgeon what the difference was between a three week
resident anaesthetic and a twenty year consultant anaesthetic.

"Very little," he informed me brutally. "the only major difference is
that when something goes wrong and a junior is anaesthetising, I
and when a consultant is anaesthetising I find out in the tea room
when it is all over."

I confronted the anaesthetic philosopher with this disturbing
information and learnt the next most important lesson.

* "Never tell the surgeon anything. There is nothing he can do and
he will only get in a flap."
* There were only four things he said to tell surgeon in time of
* "Please get the retractor off the heart."
* "Could you stop a few bleeders and give me time to catch up."
* "Could you give cardiac massage."
* "You can stop now - he's dead."

I then went on and learned the complexities of the
surgeon-anaesthetist relationship. I heard of the famous Jones
technique of anaesthesia where the anaesthetist stands at the foot of
the table and tells the surgeon how to operate while the surgeon's
assistant hold the patient on the table. I learned that fitness for
anaesthesia was a meaningless term; anyone who could lie down was
but fitness for surgery was a different matter entirely.

Fitness for surgery can be decided over the telephone by asking who
the surgeon is, where the patient is going after, and what the
operation is. All the pre-operative examination tells you is how and

I learned to understand the prima donna complexities of the surgeon
and to recognise when the operation was not going well.

* All surgeons follow the same procedure.
* Adjust retractors
* Reposition assistants
* Make bigger hole
* Change sides
* Order multiple light adjustments
* Ask for more relaxation
* Curse scrub nurse, resident, registrar, health commission,
government, anaesthetist, and deity
* Remove alternative organ and close.

Over a few further years I learned the two other important things
every anaesthetist must know.
Surgical textbooks always list causes of excessive bleeding during
They include incompatible blood transfusion, massive transfusion,
position, halothane, ether, patient too light, patient too deep,
hypoxia, hypercarbia, straining, and so on.
They never mention scalpels, tearing vessels or swabbing away clots.

In fact when a surgeon glares " Can you do anything about the
bleeding?" the best reply is "Certainly, but who will mind the
while I scrub?"

There is also a list of great surgical lies which every anaesthetist
will recognise.

* "Put him to sleep, I'll be down in five minutes."
* "He is old but he is fit."
* "You will like her, she's and old dear."
* "I haven't cross matched blood, we don't need any."
* "Don't put a tube down, it's just a quick snatch."
* "I'm just going to open, have a look, and close her."
* "She will die if I do nothing."
* "I'll be finished in ten minutes."

Surgeons appreciate a reciprocal number of anaesthetics lies as they
appreciate the law that fitness for surgery is universally
proportional to time of day.

And let surgeons beware when they hear:

* "The blood pressure is 123/72."
* "The patients is maximally relaxed and won't breathe for a week
if I give any more."
* "It's not cyanosis, it's just the bloody lighting."
* "Don't go away, it will be two minute turn around."

The subliminal implication of the lies must be appreciated by both
members of the relationship if they are to function in the best
interest of the patient, and perhaps the greatest advantage of the
lengthening postgraduate courses is to give fledgling surgeons and
anaesthetists time to appreciate the idiosyncrasies of the other.

As another cynic said: " Anaesthesia is the half asleep watching the
half awake being half murdered by the half-witted."
Only the other day when my colleague in the next theatre was
complaining bitterly: "What can I do about my mother-in-law?" the
surgeon withdrew his head from the thorax and snapped: " Why not give
her one of your anaesthetics?"

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Got a listener email asking if I wanted to master echo solely with online resources, what would I use? I sent this question to two masters of EM Echo: Haney Mallemat and Mike Mallin.

Hi all,

The one paid site I'd recommend is ; The animations are awesome and if multiple people are learning an administrator can set up a curriculum with pre and post tests complete with scheduling. I think they even have a trial version and they'll give a discount for multiple purchases. 

With respect to free resources, try

There's also a book that's pretty good and 33% is dedicated to echocardiography

Finally, there is an ultrasound iBook available by two guys who podcast, but I forget their names..., but this is more ultrasound as a collective.

Hope this helps and please do not hesitate to contact me further with any questions or guidance on other resources.



Check out 123sonography. 
Costly, but comprehensive. 



fantastic case and fantastic job. I want all of my ed doc listeners to feel comfortable floating trans-venous pacers themselves, so in the next couple of weeks look for a podcast on that very subject to hopefully move folks 1 step closer to that goal. Thanks so much for sharing

> New comment on "Podcast 10 - ccCardiogenic Shock"
> Comment:
> Hey Scott, and to the other readers out there!
> I am in my first year of practice, and since my 2nd year residency I've been listening to these podcasts, I think they are awesome, and love every bit of it. I just wanted to share my first case of cardiogenic shock that I managed just 2 days ago according to your teachings. Wonderful. It was the end of my shift 5 minutes before midnight, and this 65 yo male is wheeled in by EMS, had been complaining of Chest pain for 1 hour, was pale, diaphoretic, had a pulse of 35 and a BP that had dropped in the ambulance to 85/55 from a previous 130 systolic. He was alert and oriented and initially had warm feet and clear lungs. He had a history of heart disease but was a poor historian. EKG showed new flipped T waves in the anterolateral leads and a new 3rd degree AV Block with afib. Bedside EDE showed a grossly preserved EF. I started him on ASA, Plavix and Heparin from the get go and tried 2 atropine and a 500 cc Bolus. No improvement. Since he was on Beta-blokers I tried to reverse them with CaCl and Glucagon, no changes. Started him on Dobutamine first, then added Levophed. His BP improved minimally despite titration but HR did not. Transcutaneous pacing was unsuccessful and painful. I intubated him with RSI etomidate and succs, and tried pacing again, no changes ( I was pacing his pectorals ). His HR by this point fell down further to 28, 22 and he went into PEA. 2 min of cardiac massage and some more atropine and epi got him back to baseline. I had no on call cardiology and the closest centre was 1 hour away by ambulance. Finally managed to get ahold of a local cardio that was not on call and he placed a transcutaneous pace that finally stabilized the patient.
> Thank you Scott for your teachings, I remembered your podcast as I was managing this case and listened to it the next day for further validation. A phone FU 2 days later showed that the patient was extubated and off pressers, awaiting his definitive pacemaker.

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