Archive for the ‘Anesthesiology’ Category

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.

How did we get here?

Let’s look all the way back to the second half of the 19th century, when the use of ether, chloroform, and nitrous oxide for surgical anesthesia spread rapidly. During the American Civil War, according to medical historian Shauna Devine, PhD, “Union records show that of more than 80,000 operations performed during the war, only 254 were done without some kind of anesthetic.” Most often, the anesthetic was chloroform. “The practice was for the operating physician’s assistant to place the chloroform on a piece of cotton or towel, which had been fashioned into a cone, and then placed over the patient’s nose and mouth, preferably in the open air.”(1)

Nurses or surgical assistants gave many of these anesthetics; most American physicians weren’t interested. One notable exception in the early 20th century was Ralph Waters, MD. He described his experience starting general practice in Sioux City, Iowa, in 1913:

“A few more or less full-time surgeons, who were looked upon as specialists, employed nurses to administer ether in the mornings at hospitals and act as office nurses in the afternoons. A majority of us, ‘occasional’ surgeons, depended upon each other to act as anesthetist as occasions demanded, or sometimes we ‘borrowed’ the nurse-technician of one of our more glamorous surgical colleagues.”(2)

Outcomes were variable and sometimes tragic. A true scientist, Dr. Waters devoted the rest of his career to anesthesiology, joined the faculty of the new medical school at the University of Wisconsin in 1927, and founded the first anesthesiology residency program. However, the model of anesthesia care delivery as the practice of nursing by then was well established in America. It took decades for academic anesthesiology programs to proliferate in the U.S., but the model in America continued to be one person at the bedside, giving medications and monitoring the patient – and that person could be either a physician or a nurse.

Practicing at the top of my license?

In a fascinating ASA Monitor article a few years ago, authors Marc Steurer, MD, DESA, and Michael Ganter, MD, DESA, examined differences in the delivery of anesthesia care in the U.S. compared with Europe. Among the chief disparities:

1. “Most European countries mandate two professionals to provide anesthesia (physician and assistant, e.g., certified registered anesthesia nurse): this means that an anesthesiologist and an assistant are both present during all critical events of the anesthesia (e.g., induction and emergence). In contrast, in the U.S., the anesthesia physician may provide anesthesia alone without a trained assistant.”

2. “In most western European countries, the clinical anesthesiologist is more longitudinally involved in patient care…Not only do anesthesiologists govern the prehospital portion of emergency medicine, but also once the intrahospital care begins. Together with the primary team, an anesthesiologist is usually involved in the care of the most ill medical and surgical patients in the hospital. Also in those settings, the anesthesiologist stays with the patient for the entire critical period and provides a very helpful continuum of care. In Europe there is also a heavy involvement of anesthesiologists in both medical and surgical ICUs. Additionally, operation room (O.R.) management, preoperative and pain clinics as well as services for palliative care have been a mainstay for even small anesthesia departments for a long time. This contrasts to most U.S. practices, where anesthesiologists have predominantly focused on the intraoperative and critical care period. The broader and more longitudinal scope of practice positions European colleagues well for the development of the field.”(3)

Very interesting. These European anesthesiologists are functioning as physicians.

As an American anesthesiologist, on the other hand, I am not practicing anywhere near the top of my license much of the time. There’s satisfaction in seeing all my syringes neatly labeled and lined up in a row, but is that how I should be using my time, energy, and education? Checking the circuit and filling the vaporizer? Our residents are expected to fetch their patients in the preop holding area and – single-handedly – push the gurneys down the hall to the operating rooms, no matter how large the patient or how small the resident. No doubt they feel that their average $200,000 in medical school debt is worth it in job satisfaction, and that being a physician is all they hoped it would be.

The ICU model of care

We need to do a total restructure of procedural care to function along the same lines as ICU care, where physicians direct the care of multiple patients. Pharmacists and registered nurses – sedation nurses and critical care nurses – could be involved as part of a cost-effective bedside care team, flexing the composition of the team to the complexity of the case. Cardiologists, GI and ER physicians supervise RNs giving sedation; why don’t we?

With today’s technologies, it’s possible to monitor multiple sites at the same time. I don’t have to stay tethered to my patient with a plastic earpiece and a length of IV tubing to listen for breath sounds. (Raise your hand if you’re old enough to remember those days.) Physicians who specialize in anesthesiology can be freed up to do actual physician work, putting our medical diagnostic skills to use and functioning as team leaders, not as pawns on the OR chessboard interchangeable with nurse anesthetists in the view of too many hospital administrators.

As American healthcare moves away from fee-for-service payment into a model of giving total care to populations, which appears inevitable, we have an opportunity to redesign anesthesiology. We don’t have to be bound by 1:4 ratios and other arbitrary rules tied to submitting bills for specific services to third-party payers.

We can figure out how to provide the right care to each patient at lower cost. We can allow anesthesiologists to function as doctors of medicine all the time, not just when there’s a crisis or when we’re not busy doing bedside nursing tasks in the operating room.

To me, that sounds like a far better job description.

              (Author’s note: This commentary was first published online in Anesthesiology News on September 8, 2021.)

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1. Devine S. Chloroform and the American Civil War: The art of practice and the science of medicine. PBS: Mercy Street Blog; online publication Feb 22, 2016. Accessed June 13, 2021.

2. Gillespie N. Ralph Milton Waters: A brief biography. British Journal of Anaesthesia: Vol 21 Issue 4, April 1949; 197-214. https://doi.org/10.1093/bja/21.4.197

3. Steurer M, Ganter M. Comparison and contrast of anesthesia practice in Europe and the U.S. ASA Monitor: December 2015, Vol 79; 18-20.

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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            How the ACGME and ABA are infantilizing resident training

Not long ago, my patient in a complex thoracic case developed progressive bradycardia followed by a malignant-looking multifocal atrial arrhythmia that didn’t generate any blood pressure.

“Get out some epinephrine!” I said to my resident, who was standing closer than I was to the drug cart. The resident quickly drew up a milligram of epi, but then paused. I could almost see the thought bubble overhead: “Should I print out a label? Put a tamper-proof cap on the syringe?”

The resident – perhaps spurred on by the look in my eyes – made the right call, pushing epi immediately into the IV line and not stopping first to clean the injection port with alcohol for 15 seconds. The patient responded right away with return of sinus rhythm and a blood pressure consistent with life.

This brief but intense drama led me to ponder (not for the first time) whether the protocols and rules that infuse our days are improving safety or leading to paralysis when decisions must be made. Sometimes you have to act as you think best, accepting the possibility that your action may be vulnerable to criticism.

Even if you follow the protocol today, tomorrow it may change. Wearing masks all the time at the start of the COVID pandemic was considered a bad idea – until it wasn’t. On average, 20% of the recommendations in clinical practice guidelines don’t survive intact through even one review – on the next updated version, they’re downgraded, reversed, or omitted.

Today’s resident education process isn’t helping residents face the inevitable ambiguity of medical decision-making. No wonder residents get rattled when they find that one attending does things far differently from another. The ACGME and ABA are turning residency training into an infantilizing experience. Residents are used to studying to the test, and on the test there’s only one right answer.

Anesthesiology trivial pursuit

I don’t envy residents today. When I peer over their heads in the OR to see what they’re looking at on the computer screen, it’s often a multiple-choice question in preparation for the ABA basic exam, which looms over their first two years like an executioner’s axe. Never once has the question had any relevance to the patient or the case. The question itself seems to be part of an anxiety-ridden trivia game, geared toward testing the ability to prep for the test, not the gain of medical knowledge with any connection to patient care.

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Every death related to anesthesia is a tragedy; even more so when a minor procedure such as a colonoscopy leads to a completely unexpected death. Everyone knows that open heart surgery carries a mortality risk, but few of us walk into the hospital for a colonoscopy thinking that death is a plausible outcome.

We know so few facts at this point about what happened on January 21 at Beaumont Royal Oak Hospital in Michigan. The patient who died, sources say, was a 51-year-old man who walked into the hospital for a routine colonoscopy. He was obese, with a BMI of 39, and suffered from obstructive sleep apnea, a common problem, where people snore heavily and their breathing may obstruct intermittently while they’re sleeping. Author Charles Dickens described a portly gentleman’s sleep apnea perfectly in The Pickwick Papers:

“His head was sunk upon his bosom, and perpetual snoring, with a partial choke occasionally, were the only audible indications of the great man’s presence.”

Sleep apnea is a risk factor for anesthesia complications, especially airway obstruction, but every anesthesiologist is taught how to recognize and manage it. With the obesity epidemic in America today, sleep apnea is part of daily reality in anesthesiology practice.

According to recent reports in Deadline Detroit by journalist Eric Starkman, who has reported extensively on problems at Beaumont Health, the patient was intubated by a nurse anesthetist who ordinarily worked at another Beaumont Hospital. At the end of the procedure, the nurse anesthetist removed the breathing tube, and the patient began to “thrash around”. It isn’t clear from reports if he was trying unsuccessfully to breathe or wasn’t breathing at all. The nurse anesthetist called for help from an anesthesiologist, and an emergency back-up team was summoned, but the patient went into cardiac arrest and couldn’t be resuscitated.

How could this happen?

We’re not likely to learn further details any time soon, as NorthStar Anesthesia has refused to comment. NorthStar took over the contract for anesthesiology services at Beaumont in 2020, leading to the resignation of a number of experienced anesthesiologists and nurse anesthetists who had worked there for years. Prominent surgeons, specialists, and nurses also resigned, according to reports, concerned that extreme cost-cutting measures would compromise patient care. Senior cardiologists wrote a letter in September, according to Deadline Detroit, expressing “serious concerns that NorthStar will not be able to provide the quality of cardiac anesthesia services that we have received for several decades.”

“We oppose the concept that any Beaumont physicians can be considered replaceable commodities, or that corporate leadership can assume that we would blindly accept another group of physicians to care for our patients with life-threatening cardiac conditions,” the cardiologists’ letter stated.

In the context of this upheaval at Beaumont, we can ask these questions.

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