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(This post chronicles the recent Los Angeles visit of ASA President Jeff Plagenhoef, MD, and his Grand Rounds presentation at USC. It originally appeared on the website of the California Society of Anesthesiologists. Above, Surgeon General Jerome Adams, MD, MPH, left, with Dr. Plagenhoef.)

“Who kicked whom off the anesthesia care team?” asked ASA President Jeff Plagenhoef, MD, FASA. Which professional association refuses to work amicably with the other, he inquired of his audience at the University of Southern California on September 15, as he delivered a powerful Grand Rounds address to the Department of Anesthesiology.

In his talk, “Professional Citizenship:  Responsibilities Shared by All Anesthesiologists”, Dr. Plagenhoef emphasized that physician anesthesiologists and the American Society of Anesthesiologists (ASA) fully support nurse anesthesia practice within the physician-led anesthesia care team. In his practice as Chair of the Department of Anesthesiology at Baylor Scott and White Hillcrest Medical Center in Waco, Texas, Dr. Plagenhoef works with nurse anesthetists and with certified anesthesiologist assistants (CAAs).

In contrast to the ASA’s position, nurse anesthesia leaders at the national and state levels demand full independent practice for nurse anesthetists, and they reject physician supervision, consultation, or oversight even for complex cases involving the most critically ill patients.

“If your family member gets admitted to the hospital, and you’re willing to pound your fist on the admission desk and say, ‘I want the best possible care. No doctors!’” Dr. Plagenhoef said, “then I’ll believe that you really stand behind your principles.”  Otherwise, he said, demands for independent practice are “disingenuous” and ethically suspect.

Symbiont or parasite?

Dr. Plagenhoef listed the many ways that ASA and CSA are working on behalf of all physician anesthesiologists, including those who are not members of their professional organizations.

As one example, federal legislation to limit out-of-network payment would pose a threat to the livelihood of all anesthesiologists and hospital-based physicians, Dr. Plagenhoef explained, and the ASA is working hard to prevent it.

In California, vigilant advocacy on the part of CSA leaders and lobbyists (including late-night urgent contacts with key legislators) helped avert the passage of AB 533, which would have allowed third-party payment at Medicare rates for out-of-network services. This would have been disastrous for anesthesiologists, since our Medicare payment rates average only 33 percent of commercial insurance rates.

The anesthesiologists who choose not to pay ASA and CSA dues are taking unethical advantage of those who do, Dr. Plagenhoef said, and their relationship with their dues-paying colleagues is parasitic, not symbiotic. Refusal to support the political action committees of both organizations is short-sighted and equally unjust to the anesthesiologists who do their part as professional citizens, he said.

Supporting the anesthesia care team

Dr. Plagenhoef spoke in strong support of anesthesiologist assistant practice, saying that in his hospital nurse anesthetists and CAAs work amicably and take call together. He pointed out that CAAs have MCAT scores comparable to those of medical students, and must complete a two-year master’s degree program in anesthesiology to ready them for practice in the anesthesia care team model. CAAs are recognized by CMS as qualified anesthesia providers, and their services are compensated on an equal footing with nurse anesthetists.

The ratio of anesthesia providers to population is lower in California than in many other states, adding ammunition to the argument that there is plenty of room for CAAs to work in California without adversely affecting the job market for nurse anesthetists.

In the states like California whose governors have opted out of the CMS requirement for physician-supervised nurse anesthesia, patient access to care in rural areas has not improved at all, Dr. Plagenhoef said. The reason is that nurse anesthetists were already able to work in rural hospitals under the supervision of surgeons or other operating physicians. Nurse anesthetist payment for working in critical access hospitals is subsidized by the federal government, while physician anesthesiologists are not eligible for comparable rural pass-through funding.

In response to emotional counterargument from a few nurse anesthetists in the audience, Dr. Plagenhoef remained pleasantly unruffled, reiterating his support for nurse anesthetists working in the physician-led anesthesia care team. He explained that he presented images of negative advertising and vituperative, anti-physician tweets by nurse anesthetist leadership because it is important to be aware of them, and because nurse anesthetists elected those leaders.

The ASA refuses to engage in rebuttal, Dr. Plagenhoef said, and continues to offer full cooperation with nurse anesthetists who work in harmony with physician anesthesiologists. The ASA plans to offer continuing education modules for nurse anesthetists who want to obtain credits outside the auspices of the AANA.

Many thanks to USC!

Dr. Plagenhoef expressed warm thanks to Holly Muir, MD, Chair of the Department of Anesthesiology at USC, for her invitation to speak and for USC’s hospitality.

The CSA hosted a welcome reception for Dr. Plagenhoef at the elegant downtown California Club on September 14, made possible with the help of Rohit Varma, MD, MPH, Dean of the Keck School of Medicine at USC. CSA members including residents, faculty, and private-practice anesthesiologists from several California hospitals and universities enjoyed the chance to talk with Dr. Plagenhoef and take part in an informal question-and-answer session on ASA issues.

After his Grand Rounds appearance on Friday morning, Dr. Plagenhoef spoke with USC anesthesiology residents and then joined the CSA’s quarterly board meeting. He delivered remarks during a dinner for officers and district directors, and offered counsel at a meeting of the CSA’s Committee on Legislative Affairs.

Through Dean Varma’s generosity, Dr. Plagenhoef and Sunny Jha, MD, a physician anesthesiologist on the USC faculty, enjoyed excellent seats at the hard-fought football game between USC and the University of Texas on September 16. (USC defeated UT 27-24 in double overtime.)

“I actually think if you had a laser beam, the 50-yard mark would have passed right between us!” Dr. Plagenhoef said.

The Practical Art of POCUS

The longer you practice a profession, the easier it is not to bother to learn the next new thing. We may think we’re doing just fine without that new drug, or that new piece of expensive equipment. We’ve seen how the new drug sometimes turns out to have more side effects than benefits, and how the equipment may gather dust in the corner because no one really needed it in the first place.

That isn’t going to happen with point-of-care ultrasound, or “POCUS”, I’m willing to bet. As I learned at a weekend conference on POCUS, jointly hosted by the anesthesiology departments at UCLA and Loma Linda University, the practical applications for bedside patient care are multiplying, and the technology is improving all the time. Ultrasound isn’t just for cardiologists and radiologists any more.

Armed with a portable ultrasound probe and a tablet computer, we can evaluate patients before or after surgery and provide prompt answers to vexing clinical questions. Low blood pressure in the recovery room after surgery? A quick transthoracic echo of the heart can help you determine if the patient needs volume replacement, is evolving an acute myocardial infarction, or has a failing right ventricle due to a pulmonary embolism. The scan can be completed in minutes, with no expensive consult or dangerous delay.

When to request an ultrasound consult

Many of us in mid-career or later won’t ever need to become highly expert in the tips and tricks of obtaining perfect ultrasound views. But there are plenty of reasons to learn how ultrasound techniques can help in clinical care. My husband, a cardiac anesthesiologist, always says that in anesthesia, it isn’t necessarily what you know, it’s what you can think of in time. The single most important point to remember may be that calling a colleague with the training to do a quick bedside ultrasound may help you diagnose significant risk factors prior to surgery, or save critical time if a patient develops a problem afterward.

In the preoperative area, for example, we’ve all encountered the patient with a vague diagnosis of “moderate pulmonary hypertension” mentioned in the internist’s preoperative note without any details. We’ve all seen the patient with a hip fracture who has a heart murmur but no prior cardiac evaluation in the record. A bedside transthoracic echo — painless and noninvasive — can evaluate the size and function of the heart valves and ventricles in a matter of minutes, and prevent delay or cancellation of surgery if the result is favorable.

In the post-anesthesia care unit or ICU, abdominal ultrasound can assess volume status by looking at the diameter and compressibility of the inferior vena cava, or find immediate evidence of surgical bleeding after an abdominal or pelvic procedure. If a patient develops shortness of breath or can’t get enough oxygen in the bloodstream, thoracic ultrasound can diagnose an effusion, a collapsed lung, or pulmonary edema much faster than you can get a chest X-ray.

Driving without headlights

Most of us are quite familiar with using ultrasound for vascular access. Inserting a central venous line without it would feel like driving without headlights.

But there’s another clinical use for ultrasound that may one day seem just as indispensable:  scanning the gastric antrum to evaluate how full the stomach may be. I wasn’t aware that ultrasound technology could make that determination.

Right now we depend on patients to tell us when they last ate prior to surgery, and we have NPO guidelines (nil per os, or nothing by mouth) to help make sure that a patient’s stomach is empty prior to the induction of anesthesia. As a general rule, we assume that if a patient hasn’t eaten solid food within six to eight hours, or had any clear liquids within two hours, the stomach will be reasonably empty.

The guidelines don’t always work. Years ago, I took care of a patient who needed a brief emergency operation to drain fluid out of his inflamed knee. It was an especially busy day, and the patient was forced to wait in the emergency department for 18 hours without anything to eat before the operating room could find time and staff for his case. The patient was a successful businessman and a reliable historian; he was neither overweight nor diabetic, hadn’t needed much pain medication, and had no risk factors for delayed gastric emptying.

I elected to place a laryngeal mask airway (LMA), assuming that the patient’s stomach was empty. But shortly after he went to sleep for the procedure, he began to vomit solid food in large quantities. This was a highly dangerous situation. It was a near miracle that the patient didn’t aspirate stomach contents into his lungs, and fortunately he recovered with no ill effects. His case could have ended in tragedy. But if ultrasound of the gastric antrum had been readily available then, I would have known that his stomach was full and could have averted the entire problem with a different approach to the anesthesia.

Perhaps, in the not too distant future, we will do ultrasound of the gastric antrum before any emergency procedure, or for that matter any elective procedure. That could certainly help us quantitatively assess the risk of vomiting and aspiration. We may find that we should adapt our NPO guidelines and clinical practice based on the results in thousands of patients under differing circumstances, rather than on the limited evidence that exists today.

Hands-on learning

Certainly there is a great deal of information about POCUS available online, and videos can demonstrate the basics. In my opinion, however, there’s no substitute for the immersive experience of a conference with hands-on learning opportunities in addition to lecture content. This weekend’s POCUS conference featured presentations by a team of experts, and multiple stations where attendees could practice ultrasound techniques on simulation mannequins and live models under the guidance of experienced educators.

The course co-directors were Davinder Ramsingh, MD, of Loma Linda University School of Medicine, and two UCLA faculty members, Kimberly Howard-Quijano, MD, MS, and Jacques Prince Neelankavil, MD. Department chairs Aman Mahajan, MD, PhD, and Robert Martin, MD, lent their support to the conference and participated in an opening panel discussion on the promising future of POCUS in clinical care.

Emory University held graduation ceremonies on August 5 for the 2017 Class of Anesthesiologist Assistants (AAs), who received Masters of Medical Science degrees. While the traditional academic regalia can’t fail to evoke Harry Potter in the minds of many of us, there is some magic in the processional and the music that always makes graduation a moving, meaningful event. I had the honor of delivering the commencement address, reprinted here.

Distinguished faculty, graduates, honored guests:

It is a great pleasure and an honor to be here, and to congratulate all the graduates of the Emory University Class of 2017 on your tremendous accomplishment. Just think about all you have learned in the past two years! You’ve transformed yourselves into real anesthesia professionals, able to deliver first-class care to patients at some of the most critical times in their lives.

Today is a great time to become an anesthesiologist assistant. Just two days ago, Dr. Jerome Adams was confirmed as our country’s Surgeon General. He is the first-ever physician anesthesiologist to have that honor. Even better, he is from Indiana, where he was the State Health Commissioner, and of course Indiana is among the states where CAAs are licensed to practice. We know that Dr. Adams understands the principles of the anesthesia care team. Dr. Adams gets it – who AAs are, what you do, and how well qualified you are to care for your patients.

Another happy thought – the Secretary of Health and Human Services today is Dr. Tom Price from Georgia, an orthopedic surgeon, and a former Representative in Congress. His wife, Betty, is a physician anesthesiologist who currently serves in the Georgia state legislature.

Whatever your opinions about politics (and believe me, we’re not going there today), whether your blood runs red or blue, I think we can all celebrate the fact that we now have people in key positions who understand anesthesia; whose presence in Washington is great for AAs, for patients, and for the practice of safe, team-based anesthesia care.

All About Great Medical Discoveries

As I thought about what to say to you today, the first thing that occurred to me is that this summer marks 30 years since I finished my anesthesia training. You might be curious to know if I ever had any second thoughts, any regrets about that career choice. My answer is a resounding “no”.

I was lucky enough to get interested in anesthesia at an early age. I brought something to show you. This book was published in 1960. It’s called All About Great Medical Discoveries, and I read it when I was a little girl about 8 or 9 years old, in Amarillo, Texas. Here’s what it had to say about anesthesia, in a chapter called “The Conquest of Pain”:

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The art of deep extubation

Fair warning — this post is likely to be of interest only to professionals who administer anesthesia or may have to deal with laryngospasm in emergency situations.

There are two schools of thought about how to extubate patients at the conclusion of general anesthesia:

Allow the patient to wake up with the endotracheal tube in place, gagging on the tube and flailing like a fish on a line, while someone behind the patient’s head bleats, “Open your eyes!  Take a deep breath!”


Remove the endotracheal tube while the patient is still sleeping peacefully, which results in the smooth emergence from anesthesia like waking from a nap.

It will not require much subtlety of perception to guess that I prefer option 2. It is quiet, elegant, and people who’ve seen it done properly often remark that they would prefer to wake from anesthesia that way, given the choice.

There is art and logic to it, which I had the pleasure of learning from British anesthesiologists at the Yale University School of Medicine years ago.

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I wish I knew who coined the term “DRexit” so I could send flowers or a bottle of whiskey as a thank-you gift. There couldn’t be a more perfect term to describe the growing exodus of physicians from our beloved profession, which is turning into a morass of computer data entry and meaningless regulations thought up by people who never touch a patient.

The one bright note on the horizon for me is that physicians are starting to wake up to the trap of MOC, or mandatory maintenance of certification. It’s surprising that the Federal Trade Commission hasn’t recognized already that this is quite a racket, forcing physicians to do CME activities dictated by monopolistic certification boards which profit handsomely.

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