The Axillary Block

One patient suffering from infection of hand came to AIIMS, New Delhi, for treatment. He was seen by Professor Tarun Kumar Chaturji (fictional name) and advised I & D operation.

For Non-Medicos: I = Incision / cut in the skin over the site of infection and D = Drainage / letting out of the pus / infected material.

The infection was in advanced stage and normally require general anesthesia (G.A.) for adequate drainage / operation.

In G.A., the patient is made fully unconscious. For G.A. the patient normally requires blood investigations, a chest X-ray, E.C.G., etc. He has to be absolute fasting for 4 to 6 hours before general anesthesia, i.e. he has to stop taking even take water for at least 4 hour before the operation. He also needs to be admitted and monitored after operation. There is also the slight but definite risk of general anesthesia.

Dr. RG (fictional name) was junior resident at that time in AIIMS, New Delhi. Dr. RG was very dynamic and enthusiastic resident doctor. He was always looking for new ways to serve the patients. He thought of operating on the patient using only regional anesthesia, i. e. axillary block.

For Non-Medicos: In axillary block, a local anaesthetic injection is given near the axillary artery in the axilla (armpit) blocking the pain sensation in hand, forearm and arm.

At that time the concept of regional nerve block was in nascent stage in India. Even most of the anesthetist had not done many of the regional blocks such as axillary blocks. Dr. RG had not done this procedure before although he had studied the theory of the block in great detail and practiced mentally the entire procedure many times.

The patient was bought in the Emergency O.T. (Operation Theater) in the AIIMS, New Delhi and positioned on the operating table.

Dr. RG had especially purchased a book on anesthesia for its detail instructions on nerve blocks meant for non-anesthetist. To make sure the block will work perfectly, Dr. RG decided to follow word to word the instructions given in the book.

Since he had don sterile gloves and was doing the block, Dr. RG asked the nursing staff to read aloud the steps from the anesthesia book, so that he could follow them exactly word to word without any margin for errors.

Following the instructions, Dr. RG gave an excellent block. The patient had excellent anesthesia and did not feel any pain during the otherwise very painful procedure.

Two days later, Professor Tarun Kumar Chaturji called all the residents doctors to his office.

Professor TK Chaturji asked, “Have any of you operated on the patient with hand infection two days ago?” “Yes sir, I did the I & D in that patient”’ replied Dr. RG.

“What anesthesia did you used in the operation?” inquired the Professor.

“Axillary block sir,” proudly Dr. RG replied. His sense of pride was justified as perhaps he was the only surgeon in AIIMS, New Delhi at that time who had given such an excellent axillary block.

“Well the patient’s relatives have complained that you are doing operations while reading from books”. informed Dr. TK Chaturji. “You are treating the patients as experimental guinea pigs.”

While the patient was being operated in the Emergency OT, the patient's relatives were standing just outside the operation theater door had overheard the staff nurse reading from the book. They found that Dr. RG was doing the block for the very first time that too from reading a book.

They were shocked that even at a premier institute like AIIMS, New Delhi, doctors were learning while doing operations and had complained to Professor TK Chaturji for entrusting the operation of their patient to such a novice surgeon.

This raises some important ethical, moral and medico-legal questions. Any doctor has to do all his procedure or operation for the first time some time in his lifetime. Should we expressly tell the patient that we are doing the procedure for the first time? If a doctor does only those procedure / operation that he has done before how will his surgical repertoire improve. 

But why only the doctors? There must be a first time when a taxi driver takes his first passenger on a ride, bus driver drives the bus independently or pilot flies a commercial flight independently. Do we ask or do they tell their experience before getting in a taxi, bus, or airplane.

 

Clear practical guidelines should be made so that doctors doing or learning new procedure does not get unnecessary victimized or criticized depending on the complexity of the procedure and / or the potential for complications.

Tip: Following word to word instruction when doing any new procedure can reduce your chance of committing an error.

Tip: At that time better keep the patients relatives away from the operation theater while doing any operation for the first time (Just Joking).

(Based on true incident)

— ND

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DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

 DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm. 

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