Archive for the ‘Anesthesiology’ Category

I found myself on the wrong side of the ether screen earlier this year, having surgery on my left hand to release Dupuytren’s contracture, a genetic gift from my father and (maybe) generations of our Viking forebears.

Wondering how long it will take to heal – and when I’ll get some (any?) grip strength back in my hand – leads to reflection on the combination of brain and brawn necessary in the clinical practice of anesthesiology, something we don’t think much about when we’re young and fit.

Obviously, our clinical work demands intelligence. But we should ask this question: does it need to be as physically arduous as it currently is?

Would we reduce burnout, and keep clinical anesthesiologists in the workforce longer, if we devoted some of our collective brain power to making our workplaces less physically punishing and more ergonomically friendly? This is not an idle question to ask, considering that 55 percent of anesthesiologists (more than 23,000) in active practice are age 55 or older, according to AAMC data.

Yes, we can sit down at intervals during procedures, so we’re better off than many of our surgical colleagues. But when medical students think about their choice of specialty, few of them realize how much physical effort anesthesiologists expend:
• pushing non-motorized hospital beds
• trying to manage the airways of the morbidly obese
• helping to position heavy patients in lateral or prone position
• moving patients from gurney to OR table and back again.

Good luck calling for lifting help

If we ask for an orderly or hospital assistant to help with moving a large patient, we risk costly delay. Hospital administrators like nothing better than to document how much of the time these personnel might be standing idle and use that information to justify hiring fewer and fewer of them. Inflatable patient transfer devices such as the HoverMatt® exist, but how many hospitals have one for every operating room or procedure site?

Operating rooms are getting bigger and bigger as the need grows for robotic equipment and hybrid suites. As the footprint expands, so does the distance from preop area to OR to PACU or ICU.

During one recent day at work, my phone informed me that I walked on average half a mile during each of three OR turnovers – checking to see if the patient was ready in the preop area, checking to see if the room had been cleaned, checking to see if the nurses were ready, and finally bringing the patient to the OR. Yes, it was fine in terms of reaching my 10,000-step goal, but that amount of energy spent was exhausting as well as inefficient.

Unless you work in a small outpatient center, your experience may be similar. I’m sure there’s an electronic way to monitor all these parameters of readiness for surgery without going in person to see, but in an era of constrained resources, how many hospitals are willing to make that kind of investment?

Then there is the issue of cords – electric cords, ethernet cables. Unless your OR suite was built recently enough to have an intelligent design with ceiling-mounted booms that house electric outlets, anesthesia gas conduits, and USB cable receptacles, then you probably have a rat’s nest of cables, cords, and hoses behind your anesthesia machine. They may even be running across the floor and directly in your path as you try to make your way around the OR. This is particularly hazardous in radiology or cardiac catheterization suites where the lights are often dimmed. It’s a miracle more of us haven’t been injured tripping over them.

Am I strong enough to manage this airway?

I can remember despairing as a new resident, thinking that my hands would never be big or strong enough to ventilate large patients by mask. Luckily, the application of thought to the task soon proved that you don’t need to reach the mandible with your little finger to ventilate by mask – you just need to learn how to lift the chin and get a good mask seal.

Sadly, most of our physical challenges in the operating room aren’t as easy to work around. Even with a video laryngoscope, it still takes some upper body strength to intubate a 300-lb patient. There isn’t any reason why the same robotic technologies that enable us to see inside body cavities and manipulate instruments can’t be applied to making airway management more predictable, less dependent on physical strength, and safer for patients.

It’s time we stopped treating anesthesiologists and trainees as cheap labor. Hospital beds and gurneys should be motorized, and someone other than us should be pushing them. You can’t watch a patient’s airway and vital signs during transport if you’re trying to push the bed and avoid every obstacle in a crowded corridor.

We should be at every design meeting when operating suites are being built or renovated. We need to be involved with all stages of planning from the very start, making sure each anesthetizing site is uncluttered and well equipped. We need a voice in creating the workflow process that gets patients to and from the OR efficiently. We need to make sure that we get the right anesthesiologists freed up from clinical duty to attend those planning meetings as our champions.

Hospital administrators have no idea what we do, and (let’s be honest) aren’t interested in our welfare. They just want us to keep churning out the cases.

Our working conditions should not put us at constant peril of tripping over cables or injuring our backs while we tend to a morbidly obese patient. The fact that we put up with these conditions speaks to our dedication and – let’s face it – to our unwillingness to ask for help or admit weakness.

It’s time we put a stop to these abuses. As we tell our children – you must take care of your things if you want them to last. Our workplaces need to take better care of us.

(This article first appeared in the April 2022 issue of the ASA Monitor)

My patient and his wife didn’t understand that an anesthesiologist is a physician, despite his having been cared for by anesthesiologists during past procedures. They thought only CRNAs give anesthesia. What are we doing so wrong with our messaging, and how can we fix it?

One recent afternoon in the GI endoscopy suite (not my favorite place to work, but that’s a topic for another day), I walked up to the bedside of my next patient and introduced myself as I always do.

“Hi,” I said, holding up my name badge for the patient and his wife to see. “I’m Dr. Sibert.  I’m with the anesthesiology department and I’ll be looking after you today.”

The patient was an otherwise healthy man in his mid-30s, having his fifth endoscopy this year for a chronic though serious problem. My questions were few and he understood very well what was about to happen.

The consent process concluded, I asked if the couple had any other questions. The wife did.

“You’re a doctor when you’re not giving anesthesia?” she asked.

Wait. What?

 I’m seldom speechless, but this question took me by surprise. “Why yes,” I said, unsure how to respond.

“You’re a doctor, and you give anesthesia,” the patient’s wife said, making sure she heard correctly.  “Usually we’ve had CRNAs.”

“Yes,” I said. “I’m a doctor, and I give anesthesia all the time. I’m actually an MD who specializes in anesthesiology.”

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Nurses argue that they can perform many hands-on tasks of anesthesia care just as well as we can. So why are we still doing those tasks?

As we orient our brand-new, fresh-faced CA-1 residents to the operating room each year, I ask this question. Has anyone explained to them that much of what they’ll need to learn in the first couple of months is how to be a nurse?

We watch them struggle to draw up propofol into a syringe without spraying white foam all over themselves. We emphasize the critical difference between a surgeon’s order of 5000 units of heparin to be given SQ or IV. We teach residents how to inject medications into line ports using sterile technique, how to label a syringe correctly, and how to chart IV fluids and urine output.

Is this why they went to medical school?

Before a mob assembles with torches and pitchforks, let me be clear: there is much more to learn beyond these nursing and pharmacy tasks on the road to becoming a qualified anesthesiologist. But why are we still doing these tasks when other physicians don’t do likewise?

Do our intensivist colleagues mix up and inject antibiotics? Do our cardiology colleagues load infusion pumps with potassium or magnesium drips? Of course not. That would be a waste of their time and education.

It’s time to redesign anesthesia care delivery. We should be charting the course, not executing every change of sail. We should be performing the diagnostic and intellectual work of physicians all the time, not just some of the time. If we don’t, we shouldn’t be surprised if we continue to lose control over the future of our profession. It’s way too expensive to pay a physician to do the tasks of a nurse. Read the Full Article

Forget the pandemic, say hospital executives. What have you done for us lately?

There was a time, at the peak of the pandemic, when many of us believed that anesthesiologists finally would get the public recognition and respect we’ve earned – at a painful price – for our front-line work in airway management and critical care.

Some anesthesiologists like Ajit Rai, MD, a pain medicine specialist in Fresno, California, even boarded flights to New York last spring to help hospitals overrun with critically ill COVID patients. News reports nationwide celebrated these physicians as “healthcare heroes”.

That was then.

Today hospitals are struggling to maintain their financial stability in the face of the revenue hit they took in 2020 when elective case volumes plummeted. Total knee and hip replacements were down by 53 and 42 percent, respectively, compared with 2019 numbers, and even cardiac catheterization cases were 24 percent fewer. At least 47 hospitals closed or declared bankruptcy in 2020, with more likely to follow.

The American Hospital Association estimates that hospital revenue in 2021 could be down anywhere from $53 billion to $122 billion from pre-pandemic levels. Hospitals are still dealing with supply chain and labor market disruption, paying premium prices for traveling ICU nurses, and facing the high cost of treating resource-intensive COVID patients.

When a hospital is desperate to stay afloat, administrators are going to look anywhere they can for ways to cut costs. Subsidies to anesthesiology groups are in their crosshairs.

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If you think about scope-of-practice creep at all, you may think immediately of the advocacy efforts so many physicians have made to preserve physician-led care and discourage independent practice by nurse anesthetists or physician assistants.

You may not have paid as much attention to the current momentum to grant independent practice to nurse practitioners, or NPs, nationwide.

In addition to the District of Columbia, 28 states allow NPs full practice authority to treat and prescribe without formal oversight. Half of these states grant NPs full practice authority as soon as they gain their licenses; the other half allow it after the NP practices with physician oversight for a period of time.

My home state, California, is one of the states that has always required physician oversight. Last fall, however, Governor Newsom signed a bill, Assembly Bill 890, that will allow NPs to practice independently after they have completed a three-year transition period, practicing under physician supervision.

That was when I started to worry.

Preop assessments that make us laugh or cry

No doubt everyone who practices anesthesiology or surgery has encountered preoperative medical assessments, H & Ps, or “clearance” notes that have been so far off the mark they’re laughable. I’m not just talking about the three-word “cleared for surgery” note scrawled on a prescription pad. I recall in particular:

A consultation at a VA hospital that “cleared” my cirrhotic patient with massive ascites and coagulopathy for his inguinal hernia repair under spinal anesthesia but not general.

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