It is easy to lose sight of the core of the practice of anaesthesia. As a profession we are easily seduced and distracted by the new and exciting; quickly forgetting that satisfyingly favourable outcomes for our patients occur not because of the advances in the technology and pharmacology of anaesthesia, but rather are owed to our training and performance as anaesthetists and anaesthesiologists managing that complex system.
Our ability to understand the complex model of patient, surgeon, drugs and scalpel; to resist distraction by the blinkenlights of whatever new device has been dragged in by the friendly equipment rep; the exciting kinetics of the latest drug; or the new ventilator modes on the anaesthetic machine - our ability to conceptually simplify these things and achieve good outcomes is at the core of what we do.
Seduction of anaesthesia knowledge
When I completed my fellowship the impressive sum of advanced anaesthesia knowledge was seductive. It was hard to imagine a patient or case who would not be better served by the use of remifentanil infusions, adjunctive regional nerve blocks or fancy airway devices. Embracing the complex and advanced corners of our specialty was easy to justify as better serving the patient, but in reality owed as much to justifying the process of earning this knowledge as it does to significantly advancing excellence in our practice.
Skilfully titrating a propofol induction and sliding an airway in at Just The Right Moment will never look and feel as impressive as a multi-infusion, multi-device, polypharmacy anaesthetic - even though it contributes much more to a favourable patient experience. We are reluctant to make things look too easy.
The ability to simplify means to eliminate the unnecessary so that the necessary may speak. - Hans Hofmann
Thio, sux, tube
As a newly-minted Australian Fellow, I found myself working in Fiji for six months as a volunteer with my family. This was a wonderful experience on many levels. One of the many great things that I learnt in the South Pacific was that one could provide a very high quality and safe anaesthetic with little more than thiopentone, halothane, morphine and local anaesthetic.
While the modern trappings of anaesthetic practice contribute to the many improvements we have achieved in the care of surgical patients, our tendency to over value these additions occurs at the expense of our understanding of the core of anaesthetic practice: forming a dynamic model of where our patient exists in the nexus of the increasigly-complex medical environment.
Accept complexity. Act simply.
We need to appreciate the complexity of the anaesthetic patient. To respect the many interlocking parts of pathology, physiology and pharmacology that are expressed uniquely in each person whom we care for - and then accept and embrace that our understanding will only ever be an approximate abstraction of the true level of complexity.
The correct response then is not to add more complexity by choosing a complicated anaesthetic technique, but instead to appreciate the inherent complexities that we cannot control and simplify the systems that we can. We should observe the complex while performing the simple. Too often we delude ourselves by over simplifying our understanding of the patient-pathology-surgical system, then compound our error by adding layers of anaesthetic complexity. Observe the complex. Perform the simple.
"Make things as simple as possible, but not simpler." - Einstein
Keeping it simple
My practice now trends towards the simple. I am reluctant to add extra drugs without good reason. As an obstetric anaesthetist the single-shot spinal with bupivacaine and fentanyl is my holiest of holies; a beautifully elegant anaesthetic that resists any attempt to over complicate it. I see no reason to blunt pressor responses with alfentanil when intubating fit and healthy 20 year olds, or run complex multi-infusion anaesthetics without a very good reason.
These techniques do have a place. Our challenge is choosing that place appropriately, where it provides a better outcome for the patient rather than merely excitement for the anaesthetist.
We often forget that increased complexity comes at a cost: distraction from what truly matters, introduction of more points of failure and a need to manage increasingly complex mental models of how the system then fits together.
Sometimes it is what is left out of our anaesthetic that matters most.
Image "8 March 2012" © Stewart Chambers