Posts Tagged ‘Anesthesiology’

Six-year-old Caleb Sears:  His death was preventable

I’m not a pediatric anesthesiologist. Most of us in anesthesiology – even those who take care of children in the operating room or the ICU every day – probably will never give anesthesia to a child in a dentist’s or oral surgeon’s office. So why should we care what happens there? Dental anesthesia permits and regulations, after all, are under the authority of state dental boards, not medical boards.

The reason we should care is that healthy children have died under anesthesia in dental office settings, children like Marvelena Rady, age 3, and Caleb Sears, age 6. Unfortunately, they aren’t the first children to suffer serious complications or death in our state after dental procedures under sedation or general anesthesia, and unless California laws change, they won’t be the last.

In 2016, officers and past presidents of the California Society of Anesthesiologists (CSA) have made multiple trips to meetings of the Dental Board of California (DBC) to discuss pediatric anesthesia. We’ve provided detailed written recommendations about how California laws concerning pediatric dental anesthesia should be updated and revised. We’ve explained in testimony before the Dental Board, and in meetings with lawmakers, why we believe so strongly that the single “operator-anesthetist” model (currently practiced by dentists and oral surgeons in many states) cannot possibly be safe.

The DBC on December 30 published new recommendations for revision of California laws pertaining to pediatric dental anesthesia, posted them on its website, and sent them to the Senate Committee on Business, Professions, and Economic Development. But these recommendations ignored many of our concerns, and don’t go nearly far enough to protect children.

Further, the DBC cites statistics claiming that pediatric dental anesthesia is currently safe. But there is no database! The Dental Board has admitted to discarding records after review. They have reported on “only nine” recent cases involving death, ignoring other tragic cases of permanent brain damage and prolonged ICU admissions. Pediatricians in California recently surveyed 100 of their members and found that 29 of them — nearly one-third — knew of patients in their practices who had experienced adverse events in a dental office.

What is a single “operator-anesthetist”?

You may never have heard of a single “operator-anesthetist” because such a thing doesn’t exist in medical practice.

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“I’m your friend,” Harvard Business School Professor Michael Porter, MBA, PhD, told a sometimes skeptical audience during his keynote address at the ASA’s annual meeting, ANESTHESIOLOGY 2016. “I’m trying to help you see a better way forward, and avoid the bad outcomes that may happen if we don’t transform healthcare.”

Porter is a well-known economist, an expert on business strategy, and the author of the book Redefining Health Care: Creating Value-Based Competition on Results. In his speech to the ASA, he argued the case for redefining health care by making “value for the patient” the unifying purpose, and he urged anesthesiologists to forget pay for volume.

“How should anesthesiologists engage in bundled payments?” Porter asked. “Jump on them!”

Explaining that he has spent the past 15 years immersed in studying health care delivery, Porter said that he looks on health care as one of the world’s “most fundamental and intractable problems.” He asked listeners to think again about anesthesiology practice, and its role and responsibilities in the future of health care.

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Is there a direct connection between communication skills and the art of successful leadership? Most of us would agree that there is. But is there a direct connection between blogging and leadership? That may be more of a reach.

Can the process of writing a blog help to develop communication skills that will prove useful in leadership? In my opinion the answer is yes, but a qualified yes. Writing a blog won’t help anyone become a good writer who never learned to write competently in the first place. Perhaps even more important, writing a blog won’t help anyone become a thought leader who hasn’t developed any original thoughts.

Communicating a vision

To make a real mark in history, a leader has to communicate a vision that people understand. The vision must be powerful enough to motivate them to follow. In decades past, for instance, the men who became President of the United States typically were graduates of liberal arts education, trained in the arts of debate, oratory, and essay composition. They knew how to make their points.

No matter which end of the political spectrum you favor, most of us would agree that Presidents John F. Kennedy and Ronald Reagan were gifted communicators. Though obviously they benefited from the help of speechwriters behind the scenes, both were skillful writers on their own, as proved by their private documents and letters.

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When Arnold Schwarzenegger was governor, he decided that you and I don’t need to have physicians in charge of our anesthesia care, and he signed a letter exempting California from that federal requirement. Luckily most California hospitals didn’t agree, and they ignored his decision.

When he needed open-heart surgery to replace a failing heart valve, though, Governor Schwarzenegger saw things differently. He chose Steven Haddy, MD, the chief of cardiovascular anesthesiology at Keck Medicine of USC, to administer his anesthesia.

Now some people in the federal government have decided that veterans in VA hospitals all across the US should not have the same right the governor had—to choose to have a physician in charge of their anesthesia care.

That’s right. The VA Office of Nursing Services has proposed a new policy to expand the role of advanced practice nurses, including nurse anesthetists, in the VA system. This new policy in the Nursing Handbook would make it mandatory for these nurses to practice independently. Physician anesthesiologists wouldn’t be needed at all, according to this proposal, even in the most complicated cases – such as open-heart surgery.

If this misguided policy goes into effect, the standard of care in VA hospitals will be very different from the standard of care other patients can expect. In all 100 of the top hospitals ranked by US News & World Report, physician anesthesiologists lead anesthesia care, most often in a team model with residents and/or nurses.

The new policy isn’t a done deal yet. The proposal is open for comment in the Federal Register until July 25. Already thousands of veterans, their families, and many other concerned citizens have visited the website www.safeVAcare.org and submitted strongly worded comments in opposition. I urge you to join them.

Physician-led care teams have an outstanding record of safety, and they have served veterans proudly in VA hospitals for many years. Many university medical centers have affiliations with their local VA hospitals, where their faculty physicians deliver clinical care and conduct research. UCLA, for example, sends anesthesiologists to the VA hospital in Los Angeles, so that our veterans get the same high-quality care as wealthy patients from the enclaves of Brentwood.

Many of our veterans aren’t in good health. They suffer from a host of service-related injuries, and they have high rates of chronic medical disease. Some have been among the most challenging patients I’ve ever anesthetized. Their care required all the knowledge I was able to gain in four years of medical school, four years of residency training in anesthesiology, and countless hours of continuing medical education.

No VA shortage of anesthesia care

It’s clear, of course, why the VA is proposing the change in the Nursing Handbook. The reason is the scandal over long waiting times for primary care. Proponents argue that giving nurses independent practice will expand access to care for veterans.

But there’s no shortage of physician anesthesiologists or nurse anesthetists within the VA system. The shortages exist in primary care. A solution that might help solve the primary care problem shouldn’t be extended to the complex, high-tech, operating room setting, where a bad decision may mean the difference between life and death.

The VA’s own internal assessment has identified shortages in 12 medical specialties, but anesthesiology isn’t one of them. The VA’s own quality research questioned whether a nurse-only model of care would really be safe for complex surgeries, but this question was ignored. The proposed rule in the Federal Register lists as a contact “Dr. Penny Kaye Jensen”, who in fact is not a physician but an advanced practice nurse who chooses not to list her nursing degrees after her name. The lack of transparency in the proposal process is disturbing.

In 46 states and the District of Columbia, state law requires physician supervision, collaboration, direction, consultation, agreement, accountability, or direction of anesthesia care. The proposed change to the VA Nursing Handbook would apply nationally and would override all those state laws, which were put in place to protect patients.

In Congress, many senators and representatives on both sides of the aisle recognize the need to continue physician-led anesthesia care for veterans. Representatives Julia Brownley of California’s 26th District and Dan Benishek, MD, of Michigan’s 1st District are strong advocates for veterans’ health. They have co-authored a letter (signed by many in Congress) to VA Secretary Robert McDonald, urging him not to allow the destruction of the physician-led care team model as it currently exists within the VA system.

Governor Schwarzenegger’s heart surgery is a matter of public record. He has spoken about it openly on television, and he graciously invited the whole operating room team to his next movie premiere. I was lucky enough to go to the premiere too, because his anesthesiologist, Dr. Haddy, happens to be my husband.

But I didn’t set out to write this column on behalf of my husband. I’m writing on behalf of my father, who is now 93, landed on the beach at Normandy on D-Day, and miraculously survived the rest of the war as a sniper. And I’m writing on behalf of all the men and women who have served our country, and who deserve the best possible anesthesia care from physicians and nurses who want to work together to take care of them. If we don’t defeat the proposed change in the VA Nursing Handbook, they all lose.

A better pathway to acute care

When patients need acute interventional care, coordinating the transitions away from and back to primary care is a challenge. The common pathway for these patients, no matter what their diagnosis, is an encounter with anesthesiology. But it often happens too late in the process. If we’re involved earlier, physician anesthesiologists can help reduce procedure risk, control costs, and improve the long-term health of this high-risk, high-spend population.                    

The numbers haven’t changed significantly in several years—only five percent of the U.S. population consumes a full 50 percent of annual health care spending, and just one percent is responsible for nearly 23 percent of spending.

Within the top 10 percent of high spenders, most (nearly 80 percent) are age 45 or older. About 42 percent are persistent high consumers year after year, while the majority requires high spending only on an occasional basis. These episodes of high health care consumption often involve surgery or other invasive procedures in the older patient population.

The experience of undergoing surgery inevitably disrupts a patient’s normal routine of care, even if the surgery is a common elective procedure such as a total joint replacement. Too often, the primary care physician may be unaware that the patient has actually undergone surgery.

Even if the patient’s primary physicians are informed of the plan for elective surgery, they may be left out of the loop regarding discharge planning, the need for post-acute care and rehabilitation, and any changes made to the patient’s medication and diet regimen. Lapses in care and deterioration of chronic medical conditions may result, with the frail, older patient population clearly at highest risk.

Why we should rethink current practices

Within every community population, a subset of patients will be in need of procedural care at any point in time. This care may involve an operation. Or it may involve a substantial, invasive procedure for diagnosis or treatment, such as ablation of cardiac arrhythmia, ERCP (endoscopic retrograde cholangiopancreatography), or insertion of an endovascular stent.

The common pathway for this entire population subset, regardless of the diagnosis or any other factors, is an encounter with anesthesiology before, during, and after the procedure. Today, that encounter often begins way too late in the process.

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