Posts Tagged ‘American Society of Anesthesiologists’

How reporter Jan Hoffman and the New York Times manage to insult female physicians and get their facts about anesthesia so wrong all at the same time

My husband and I, both anesthesiologists, enjoy our Sunday mornings together — coffee, the New York Times, a leisurely breakfast. No rush to arrive in the operating room before many people are even awake.

Today, though, seeing reporter Jan Hoffman’s front-page article in the Times — “Staying Awake for Your Surgery?” — was enough to take the sparkle out of the sugar. Her article on how much better it is to be awake than asleep for surgery reminded me why I left a plum job as a reporter for The Wall Street Journal to go to medical school — because reporters have to do a quick, superficial job of covering complex issues. They aren’t experts, but seldom admit it.

Physician anesthesiologists across the country are likely to face patients on Monday morning who wonder if they ought to be awake for their surgery. The answer to that question may well be “no”. But according to Ms. Hoffman, that answer reflects “physician paternalism”, and makes us opponents of the “patient autonomy movement”, because a patient should have the right to choose to be awake.

It’s not that simple.

Knee scope? C-section? Being awake is nothing new

Ms. Hoffman decided to stay awake for her knee arthroscopy, which is hardly front-page news. Many people, especially athletes, are fascinated to watch their own knee surgery. But the spinal anesthetic Ms. Hoffman enjoyed is still a type of major anesthesia, and it required anesthesia expertise for its safe insertion and her smooth recovery. Cardiac arrest may occur under spinal anesthesia, even in young and otherwise healthy patients, and every patient needs to understand that “awake” isn’t the same thing as risk-free.

As recently as 20 years ago, most orthopedic surgeons wanted their patients asleep under general anesthesia for any major operation such as a total hip or knee replacement. It was physician anesthesiologists who gradually turned opinion in favor of regional anesthesia by developing spinal needles that reduced headache risk, and ultrasound-guided techniques that made nerve blocks safer, faster, and more reliable. The “patient autonomy movement” had nothing to do with it. Ms. Hoffman’s implication that anesthesiologists have been the followers rather than the leaders in regional anesthesia is especially insulting to the American Society of Regional Anesthesia and Pain Medicine (ASRA), founded in 1923.

Obstetric anesthesiologists deserve credit for demonstrating that expert regional anesthesia — epidural and spinal anesthesia for cesarean section — plays a major role in today’s low rates of complications and death during childbirth. The Society for Obstetric Anesthesia and Perinatology (SOAP) is about to celebrate its 50th year of advocating for the health of pregnant patients and newborns, and for safe, awake childbirth. Dr. Virginia Apgar, lest we forget, was an anesthesiologist first and the inventor of the Apgar score second.

When “awake” isn’t an option

Today’s “minimally invasive” surgical techniques, such as laparoscopy, have made surgery possible for millions of patients with less pain, smaller incisions, and faster recovery. But here’s a fact that Ms. Hoffman may not appreciate:  general anesthesia makes these techniques possible.

General anesthesia with complete muscle relaxation is often a must for minimally invasive and “robotic” surgery performed with small cameras and other instruments inserted into the chest or abdomen. I often tell my residents never to use the word “paralysis” around patients because it might alarm them unnecessarily. “Say ‘muscle relaxation’ instead,” I advise. But the fact is that the patient’s muscles must be paralyzed under anesthesia for the surgeon to work on a motionless target.

The patient’s breathing has to be precisely controlled, which means that the anesthesiologist must insert an endotracheal (breathing) tube and manage the settings on the ventilator to breathe for the patient until the operation is done. For some operations, the patient must be in a steep head-up or head-down position, with both arms snugly tucked at the sides, and must remain in that position for hours.

After the patient is safely asleep under general anesthesia, we give “muscle relaxants” to block the ability to move, breathe, or cough. The actions of these medications are reversed at the end of surgery so that the patient starts to breathe again. Then we allow the patient to wake up. This is all part of the profession and specialty of anesthesiology. Like the making of sausage and political deals, we keep this part of the work quietly behind the scenes. I can’t imagine that any patient would want to be awake for it.

Cheaper surgery without anesthesia?

Absolutely. It’s cheaper to have surgery without anesthesia. If I needed a small procedure that could be done in my doctor’s office under local anesthesia, of course that’s what I would choose. A good rule to live by is not to take any medication you don’t need, and that includes pain-killers, sedatives, and anesthesia medications.

But Ms. Hoffman is misleading patients to make them think that they can opt to have a procedure without anesthesia as a “personal budget” choice.

Even if a patient prefers local anesthesia or minimal sedation alone, the procedure might not be tolerable due to anxiety, pain, or the inability to lie still. That’s not always possible to predict. If the patient needs the option of converting to deep sedation or general anesthesia, then the services of the anesthesia department’s physicians and nurses will be involved and must be scheduled in advance. They aren’t free, any more than the services of your surgeons and operating room nurses are free. There isn’t a “bench” of anesthesiologists on stand-by just in case you need us. Either we see a patient in advance, perform a pre-anesthesia assessment, remain with the patient during the procedure, and supervise the recovery period — or we’re not involved at all, and will be busy taking care of patients elsewhere. That’s reality.

Watch who you call ‘paternalistic’

As a specialist in thoracic anesthesia, I’ve had plenty of opportunity to reflect about the importance of my job. As I watch a surgeon do a delicate dissection to peel lung cancer away from a major artery in the chest, I sometimes think how one tiny patient movement or cough could lead to catastrophic bleeding. It’s my job to make sure that doesn’t happen, and to keep the patient’s oxygen level safe while only one lung is being ventilated.

If I tell my patient in the morning that surgery has to be done under general anesthesia, I’m not being paternalistic. Nor does that decision depend on “the flexibility of the anesthesiologist”, as Ms. Hoffman would have it. Many operations — minor ones as well as major — can’t be done without general anesthesia.

Ms. Hoffman did my future patients no service by suggesting that being awake for surgery is necessarily better.(Please visit the American Society of Anesthesiologists website for accurate information about anesthesia.) Her simplistic views may mislead patients to believe that a Google search and a quick read of the New York Times will equip them to choose the anesthesia flavor of the day off a menu. If you want to push back against “authority figures”, it would be better to take that energy elsewhere and let your anesthesiologist and your surgeon — many of whom today are women — do our work.

Finally, I question the wisdom of allowing Esther Voynow, the patient featured in Ms. Hoffman’s story, to drive herself home after surgery on her right wrist. While she may have been perfectly awake, that isn’t the only skill involved in driving a car. If she had caused an accident, the surgeon and the hospital would have risked serious liability. The only good news about that questionable decision — there was no anesthesiologist involved.

Certified Anesthesiologist Assistants (CAAs) are superbly trained anesthesia caregivers, loyal supporters of physician anesthesiologists, and eager to come to work in every state if we can just get state legislatures to grant them licenses to practice!

That was the message I heard clearly in Denver this past weekend, as a guest faculty member at the 40th annual meeting of the American Academy of Anesthesiologist Assistants (AAAA). More than 600 CAAs and student AAs from across the country made the journey to Colorado, one of the 18 states where CAAs are currently able to practice their profession, to hear lectures, promote advocacy, and attend workshops.

Anyone who still doubts that CAAs are champions of our profession should have been there! The ASA cosponsored the meeting, and ASA President-Elect Jeff Plagenhoef, MD, delivered this year’s Gravenstein Memorial Lecture, a powerful talk on “Professional Citizenship” in anesthesiology.

Ready to relocate!

“Many experienced CAAs are telling me they are ready to drop everything and relocate to California whenever we can work there,” said Megan Varellas, CAA, the immediate past president of the Academy. Her viewpoint was echoed by other CAAs I spoke with, including Maria Williamson, CAA, and her fiancé, Jeff Carroll, CAA, who currently practice in Florida. Ms. Williamson’s parents live in southern California, and the couple would be eager to move here if they could work.

The ASA strongly supports CAAs as members of the physician-led anesthesia care team. Their master’s level educational programs are located at medical schools, not nursing schools, and physician anesthesiologists direct their training. CAAs work exclusively within the anesthesia care team, under physician anesthesiologist supervision. Their services are attractive to many physician-only practices that want to move toward a care team model.

At present, though, despite a shortage of qualified anesthesia practitioners in California, CAAs can’t yet work here. Last year, CSA sponsored AB 890, a bill championed by Assembly Member Sebastian Ridley-Thomas (D-Los Angeles), which would have recognized CAA practice in California. The bill stalled in the Appropriations Committee, but CSA hasn’t given up. We plan to introduce a new bill to authorize full CAA licensure, and realize that it’s typical for these legislative efforts to take more than one attempt to pass.

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This column ran first in the online magazine for medical students, “in-Training”

In case you were wondering — robots won’t replace anesthesiologists any time soon, regardless of what the Washington Post may have to say. There will definitely be a place for feedback and closed-loop technology applications in sedation and in general anesthesia, but for the foreseeable future we will still need humans.

I’ve been practicing anesthesiology for 30 years now, in the operating rooms of major hospitals. Since 1999 I’ve worked at Cedars-Sinai Medical Center, a large tertiary care private hospital in Los Angeles.

So what do I think today’s medical students should know about my field?

A “lifestyle” profession?

For starters, I have to laugh when I hear anesthesiology mentioned with dermatology and radiology as one of the “lifestyle” professions. Certainly there are outpatient surgery centers where the hours are predictable and there are no nights, weekends, or holidays on duty. The downside? You’re giving sedation for lumps, bumps, and endoscopies a lot of the time, which can be tedious. You may start to lose your skills in line placement, intubation, and emergency management.

Occasionally, though, if you work in an outpatient center, you’ll be asked to give anesthesia for inappropriately scheduled cases on patients who are really too high-risk to have surgery there. These patients slip through the cracks and there they are, in your preoperative area. Canceling the case costs everyone money and makes everyone unhappy. Yet if you proceed and something goes wrong, you can’t even get your hands on a unit of blood for transfusion. To me, working in an outpatient center is like working close to a real hospital but not close enough — a mixture of boredom and potential disaster.

The path I chose is to focus on high-risk inpatient cases. I especially enjoy thoracic surgery, with the challenges of complex patients and one-lung ventilation. You can bring me the sickest patient in the hospital setting — where I have all the monitoring techniques, resuscitation drugs, blood products, bronchoscopes, and anything else I might need — and I’ll be perfectly happy. The downside: a practice like mine tends to be stressful and tiring, and I never know the exact time that the day will end. Hospitals that offer Level I trauma and high-risk obstetric care are required to have anesthesiologists in house 24 hours a day, 365 days a year. There’s no perfect world.

What type of person is happy as an anesthesiologist?

Even though women comprised 47% of the US medical school graduates in 2014, only about 33% of the applicants for anesthesiology residency were women. I’d be interested to hear from all of you as to why fields such as pediatrics and ob-gyn tend to be so much more attractive to women, because I genuinely don’t understand it. But I do have a few thoughts as to the type of person who is happy or unhappy as an anesthesiologist.

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“I’m here to say ‘Yes, they can,’ which is different from ‘Yes, they always do,’” says James Moore, MD, President-Elect of the California Society of Anesthesiologists (CSA).

To the contrary, enthusiasm for electronic medical records (EHRs) is part of a “syndrome of inappropriate overconfidence in computing,” argues Christine Doyle, MD, the CSA’s Speaker of the House.

The two physician anesthesiologists (and self-identified “computer geeks”) squared off in a point-counterpoint debate in New Orleans as part of the American Society of Anesthesiologists (ASA) annual meeting, with Dr. Moore defending the benefits of EHRs and Dr. Doyle arguing against them. Dr. Doyle chairs the ASA’s Committee on Electronic Media and Information Technology, while Dr. Moore leads the implementation of the anesthesia information management system (AIMS) at UCLA.

Legibility, accuracy, quality

Dr. Moore defined safety in anesthesia care as “minimizing patient injury resulting from or occurring during anesthesia, and keeping surgeons from harming patients any more than they have to.” He said that computerization contributes to safe anesthesia care by improving legibility, offering clinical decision support with readily available reference information, and providing alerts and reminders.

Computer tracking of the anesthetized patient’s vital signs is more accurate, Dr. Moore said. It prevents the “normalization” of blood pressure that tends to appear on the paper record. Quality reports are easier to generate and outcomes are easier to measure with EHRs in place, he noted. “Postop troponin levels and acute kidney injury are easy to track.”

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Not so many years ago, surgeons wouldn’t operate on patients they considered too old to tolerate the stress of anesthesia and surgery.  Today, though, patients of every age—from Baby Boomers to the Greatest Generation—undergo anesthesia safely for surgery and diagnostic procedures.

Realistically, even if you believe that 60 is the new 40, concerns about having anesthesia are different for 60-year-olds and their parents than for 20-somethings.  Here are answers to ten frequently asked questions about anesthesia for those of us–myself included–who no longer need to worry about being asked for ID if we order a drink.

Who will be giving me anesthesia? 

It’s important to find out who will be in charge of your anesthesia care.  In some hospitals, a physician anesthesiologist (a medical doctor who specializes in anesthesia) will be personally taking care of you.  In others, a physician anesthesiologist may be supervising anesthesiologist assistants, residents, or nurse anesthetists on an anesthesia care team.  Sometimes a nurse anesthetist may work alone without physician oversight, though this is not permitted in many states.  Ask your surgeon or call the hospital in advance to make sure a physician anesthesiologist will be on site.

What is the chance of a serious complication from anesthesia? 

Better medications and monitoring equipment have made anesthesia remarkably safe, which is why we can offer anesthesia today even to patients in their 90s.  A better question to ask would be this:  What is my chance of complications from the whole experience of anesthesia and surgery? The American College of Surgeons has developed an easy-to-use online calculator that can predict your outcome risk depending on the type of surgery, your age, and any medical problems you already have.  The analysis estimates your chance of a heart attack, pneumonia, infection, and other problems that may occur after anesthesia and surgery.

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