Archive for the ‘Medical Education’ Category

It’s early May in Los Angeles, and dystopian reality is here – storefronts boarded up; people (if they’re out at all) wearing sinister-looking black facemasks. Inside the hospital, everyone wears a mask all the time, no one gathers in clusters to chat, and even the tail-wagging therapy dogs must be sheltering at home because they’re nowhere to be seen.

One change I didn’t see coming was a metamorphosis in airway management.

Guidelines developed for the intubation of COVID-19 patients are evolving into the new normal whether a patient is infected or not. This is even more remarkable since anesthesiologists consider ourselves experts in airway management, and many of us (how can I put this kindly?) hold firmly to our opinions. Who would have thought old habits could change? But airway management this year is different and scarier. Remember when we didn’t think of it as hazardous duty?

Who still “tests” the airway?

Consider the question of whether to “test the airway” before giving any neuromuscular blocker (NMB) during a routine anesthesia induction. Some of us believe that it offers a measure of safety, because you can back out and wake the patient up if you can’t ventilate. Those (like me) who don’t do it quote studies that demonstrate more effective mask ventilation with larger tidal volumes after NMB, and point out that if you can’t ventilate, most people will give NMB anyway.

That controversy seems to have gone into hiding. Today, the guidelines for intubating a patient with proven or suspected COVID-19 recommend rapid-sequence induction (RSI) to reduce the risk of the patient coughing and spraying the area with aerosolized coronavirus. No one in that situation seems worried about testing the airway.

What about the patient who is asymptomatic, and has a recent negative COVID-19 test result? There is legitimate concern that the patient could still be in the early, asymptomatic stage of infection, and the incidence of false negative results from COVID-19 testing could be as high as 30%. By that logic, we should treat every patient as a PUI, and perform RSI on all comers. It would be interesting to survey anesthesia professionals and see how many now perform RSI as their default approach. Certainly, residents now ask me on nearly every case if the plan is RSI, and I hear from colleagues at other institutions that my experience isn’t unique.

What about extubation?

If we don’t want coughing on intubation in the era of COVID-19, logically we wouldn’t want it on extubation either. Awake extubation, especially in the hands of novices, can include an alarming display of coughing and struggling by the patient, accompanied by cries of “Open your eyes! Take a deep breath!” by the person at the head of the table. More coughing follows as the tube comes out. In contrast, a recent review article on the care of COVID-19 patients advises removing the endotracheal tube “as smoothly as is feasible”. For our colleagues in the United Kingdom who are accustomed to deep extubation, this is routine. In America, it isn’t.

Anecdotally, there is new interest stateside in the art of deep extubation. If you’re experienced with it, there couldn’t be a better indication for deep extubation than the COVID-19 pandemic, and you’ll probably hear less backtalk from those who still think it’s dangerous. However, anyone who hasn’t been well trained in deep extubation, or who hasn’t practiced it in quite some time, has no business trying it in a high-stress situation. There are other ways – dexmedetomidine, lidocaine, ketamine, opioids – to achieve a tranquil, cough-free emergence.

How will medical students and residents learn?

As the universities evacuated this spring, the medical students disappeared along with the undergraduates. It’s unclear when they’ll be back or how they’ll make up the lost time. The anesthesiology residents are here, but at many programs they’ve been kept away from the intubations in the emergency department (ED) and the COVID-19 wards.

In the operating room, it would be interesting to know how many anesthesiologists find that they’re less willing now to let a resident struggle with mask ventilation, if they allow it at all. Certainly, it’s not easy to teach mask ventilation today with so many obese patients. Residents with smaller hands have difficulty reaching the mandible even on normal-size adults, and need to learn alternate methods such as the modified chin-lift. If they have fewer opportunities to ventilate by mask, it will be tough to learn to do it well.

Will COVID-19 succeed in making the video laryngoscope (no matter what brand you choose) the default standard of care? Will residents ever learn fiberoptic intubation? The same guidelines that encourage RSI also recommend video laryngoscopy and avoiding fiberoptic intubation for any patient suspected of COVID-19. Cost may be the only reason keeping many departments from adopting video laryngoscope use today for every case. Why drive without headlights when headlights can be had? Those of us who are old enough will recall when we had the same kind of standard-of-care discussions about pulse oximetry, end-tidal CO2 monitoring, and the use of ultrasound for central lines. Perhaps COVID-19 simply will push us sooner toward video laryngoscopy for everyone.

Aerosol generation?

Here’s a question: Is routine airway management in the operating room, under controlled conditions, really the same in terms of aerosol generation as airway management in the ED or the ICU? Does it make sense to treat them as equivalent?

Imagine that we have a patient who is afebrile and asymptomatic, with a negative COVID-19 test result documented within 48 hours. We are preparing for a routine surgical or diagnostic procedure. We preoxygenate and administer an hypnotic agent and NMB. Assuming a good mask seal and easy ventilation, what quantity of aerosolized respiratory secretions actually would escape into the air? What is the real risk of coronavirus transmission?

Intubating this patient, who is completely paralyzed, should generate no coughing at all. It’s completely different from approaching the critically ill patient in the ED or ICU with a high viral load, who is likely to be coughing relentlessly and receiving high-flow oxygen. Similarly, smooth extubation of the normal surgical patient should produce little or no coughing, and minimal aerosol generation. It’s still reasonable, if you wish, to wear higher-level personal protective equipment (PPE) than the simple surgical mask and eye protection we wore before COVID-19, but the practical risk seems far less, and wearing full head-to-toe PPE seems wasteful.

The “post-aerosol pause” – a waiting period after intubation and extubation before allowing personnel in or out of the operating room – is meant to allow time for air exchange to clear the air of contaminants. Should it be done only for patients with confirmed or suspected COVID-19, or expanded to all patients, given the risk of asymptomatic infection and false-negative tests? The time required to remove airborne contaminants varies with the room’s air exchange rate per hour. The pause would need to last 14 minutes to achieve 99 per cent removal in a room with 20 air exchanges per hour, or as long as 46 minutes if there are only 6 exchanges per hour. Now that elective surgery is ramping up again, production pressure and sheer human impatience has buried the post-aerosol pause except for urgent cases in patients with proven or suspected COVID-19.

Will we ever get back to “normal”?

No one knows the answer. Writing today, I suspect that many anesthesia professionals may be wearing N95 masks for intubation, extubation, bronchoscopy, and upper endoscopy (including TEE) for a long time to come, even after the pandemic is over. It’s hard to walk back PPE recommendations, or eliminate worry about some new lung pathogen yet to come.

As long as we don’t let fear stand in the way of common sense, or let donning and doffing PPE distract us from patient care, we can make productive use of some lessons learned from COVID-19. But how we think about  airway management may never be quite the same.

Author’s note: This article was written in May 2020 for the American Society of Anesthesiologists’ monthly magazine, the ASA Monitor. It was published online ahead of print on June 29, 2020.

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Selected references:

Warters RD, Szabo TA, Spinale FG, DeSantis SM, Reves JG. The effect of neuromuscular blockade on mask ventilation. Anaesthesia 2011; 66:163-167. DOI: https://doi.org/10.1111/j.1365-2044.2010.06601.x 

Sachdeva R, Kannan TR, Mendonca C, Patteril M. Evaluation of changes in tidal volume during mask ventilation following administration of neuromuscular blocking drugs. Anaesthesia 2019; 69:826-831. https://doi.org/10.1111/anae.12677

Priebe HJ. Another nail in the coffin of the practice of checking mask ventilation before administration of a muscle relaxant. Anesth Analg 2019; 129(3):e103-e104. doi: 10.1213/ANE.0000000000004260

Broomhead RH, Marks RJ, Ayton P. Confirmation of the ability to ventilate by facemask before the administration of neuromuscular blocker: a non-instrumental piece of information? British Journal of Anaesthesia 2010; 104(3): 313-317. https://doi.org/10.1093/bja/aep380

Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation. A review of 50,000 anesthetics. Anesthesiology 2009; 110: 891–897. https://doi.org/10.1097/ALN.0b013e31819b5b87

Orser B. Recommendations for endotracheal intubation of COVID-19 patients. Anesth Analg 2020; 130(5):1109-1110. DOI: 10.1213/ANE.0000000000004803

ASA and APSF Joint Statement on Perioperative Testing for the COVID-19 Virus. Online publication April 29,2020. https://www.apsf.org/news-updates/asa-and-apsf-joint-statement-on-perioperative-testing-for-the-covid-19-virus/ [Accessed April 30, 2020]

Infectious Diseases Society of America Guidelines on Infection Prevention in Patients with Suspected or Known COVID-19. Online publication April 27, 2020. https://www.idsociety.org/practice-guideline/covid-19-guideline-infection-prevention/ [Accessed April 30, 2020]

Anesi GL. Coronavirus disease 2010 (COVID-19): Critical care issues. UpToDate online publication, last updated April 24, 2020. https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-critical-care-issues?source=related_link#H3884198318 [Accessed April 30, 2020]

Rajappa GC, Parate LH, Tejesh CA, Prathima PT. Comparison of modified chin lift technique with EC technique for mask ventilation in adult apneic patients. Anesth Essays Res 2016; 10(3):643-648. doi: 10.4103/0259-1162.191111

Wald SH, Arthofer R, Semple AK, Bhorik A, Lu AC. Determination of length of time for “post-aerosol pause” for patients under investigation or positive for COVID-19. Anesth Analg 2020; published ahead of print April 28, 2020. https://journals.lww.com/anesthesia-analgesia/Citation/9000/Determination_of_Length_of_Time_for__Post_Aerosol.95646.aspx [Accessed April 29, 2020]

Sibert K, Long J, Haddy S. Extubation and the Risks of Coughing and Laryngospasm in the Era of Coronavirus Disease-19 (COVID-19). Online publication at Cureus.com, May 19, 2020. https://www.cureus.com/articles/31997-extubation-and-the-risks-of-coughing-and-laryngospasm-in-the-era-of-coronavirus-disease-19-covid-19

Elegy for giant conventions

ANESTHESIOLOGY 2019 may have been the last old-school, convention-size, professional meeting I will ever attend. I could be wrong, but it may mark the end of an era. Disruptive change to the convention business model was inevitable, though hastened by COVID-19. On June 5, ASA leadership announced that the 2020 annual meeting will be virtual — for the first time, but perhaps not the last. Does this news herald disaster or opportunity?

When I was a resident attending my first ASA annual meeting, the huge convention center struck me as the mother lode of anesthesiology knowledge, with lectures and workshops that couldn’t be found anywhere else. Today, I wonder why I would travel across the country to attend a refresher course lecture in a freezing-cold meeting room, when I can watch similar content on YouTube or VuMedi for free, in comfort?

Professional associations could take this moment to move decisively into the video/podcast market. Speakers could record their own lectures, pro-con debates, and panel discussions, and societies like ASA and CSA could post all the content on proprietary video and podcast channels for members to access year-round. Think of the money we could save in travel and the cost of renting convention centers. Giant conventions at the ASA level are limited to only a few cities, most of which wouldn’t be my choice to visit.

The future of exhibit halls?

Corporate interest in buying exhibit space at anesthesiology meetings was fading fast, even before COVID-19. Why pay to send people and equipment to exhibit halls when mergers and acquisitions have centralized all the purchasing power? As recently as ten years ago, many anesthesiologists were able to influence which laryngoscopes or epidural kits their departments would order. Today, people who negotiate purchasing contracts typically work in the central offices of health systems, not in operating rooms. Today, most of us can do little more than complain about our inadequate stock of video laryngoscopes or the maddening electronic health record we’re compelled to use.

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“Each man or woman is ill in his or her own way,” Dr. Abraham Verghese told the audience at the opening session of ANESTHESIOLOGY 2019, the annual meeting of the American Society of Anesthesiologists. In his address, titled “Humanistic Care in a Technological Age,” Dr. Verghese said, “What patients want is recognition from us that their illness is at least somewhat unique.”

Though we in anesthesiology have only limited time to see patients before the start of surgery, Dr. Verghese reassured listeners that this time has profound and immense value. He pointed out that there is “heightened drama around each patient” in the preoperative setting. “Everything you do matters so much,” he said. What patients look for are signs of good intentions and competence, and the key elements are simple: “the tone of voice, warmth, putting a hand on the patient.”

Dr. Verghese, a professor of internal medicine at Stanford University and the acclaimed author of novels including the best-selling Cutting for Stone, believes that patient dissatisfaction and physician burnout are the inevitable consequences of today’s data-driven healthcare system, where physicians seldom connect with patients on a personal level or perform a thoughtful, unhurried physical examination. “Our residents average 60 percent of their time on the medical record,” he said.

“It’s the ‘4000 clicks’ problem,” Dr. Verghese said, citing a study in which emergency room physicians averaged 4000 mouse clicks over a 10-hour shift, and spent 43 percent of their time on data entry but only 28 percent in direct patient contact.

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The Hahnemann Disaster

Though the news at first stayed local in Philadelphia and the northeast, it’s gaining traction nationwide. ZDoggMD is on it. Bernie Sanders held a rally.

What happened? The venerable Hahnemann University Hospital, the main teaching hospital for Drexel University College of Medicine in Philadelphia, is bankrupt and will soon close its doors after more than 170 years as a safety-net hospital serving inner city patients.

Why should we care? After all, there are other teaching hospitals in the immediate area with capacity to absorb the patients, and they had several months’ warning to prepare.

We should care for many reasons, but I’ll start with the plight of the 570 residents and fellows who are being displaced from their jobs. Getting a residency position in the first place is a perilous process – there aren’t enough spots for all the graduating medical students who want them. Only 79% of the more than 38,000 applicants in 2019 snagged a first-year or internship position in a residency program.

So the Hahnemann residents – the “Orphans from HUH”, as they’ve started to call themselves – are scrambling on their own to find new jobs at a time when most residents are thankfully settling in to the new academic year. There’s no organized program to help them.

Even for the residents who’ve already found new positions, there are other boulders in the road. To begin with, they haven’t been released yet. They can’t start their new jobs and the Medicare funding for their positions is still tied up in bankruptcy court.

They’re still at work, wandering around a nearly empty Hahnemann with only a handful of patients left. The ER isn’t admitting any new patients and will shut down completely on August 16. The labor-and-delivery ward has closed. The new interns aren’t gaining any real experience and will be lagging behind their peers wherever they go.

“Doctors have been writing notes to update plans of care and people have come in as part of the liquidation to take away their computers,” a third-year internal medicine resident named Tom Sibert, MD, told Medscape reporter Marcia Frelick last week.

Tom Sibert? Any relation? Why yes; he’s my son. You can understand, I’m sure, why I went into full-blown mama lion fury when the Hahnemann situation blew up, and why I was beside myself with worry until he locked in an acceptance to an excellent program where he’ll finish his training.

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Once again, it’s Physician Anesthesiologists Week, and it’s a great time to celebrate our specialty’s many successes and accomplishments.

But we’re wasting an opportunity if we don’t also take this week to consider the state of the specialty today, and what it could or should mean to be a physician anesthesiologist 20 or 30 years from now.

There is no question that a seismic shift is underway in healthcare. Look at how many private anesthesiology groups have been bought out by—or lost contracts to—large groups and corporations; look at how many hospitals have gone bankrupt or been absorbed into large integrated health systems. Mergers like CVS with Aetna are likely to redefine care delivery networks. Where does a physician anesthesiologist fit into this new world?

An even better question to ask is this: Is your group or practice running pretty much as it did 20 years ago? If so, then my guess is that you are in for a rude awakening sometime soon. One of two scenarios may be in play:  either your leadership is running out the clock until retirement and in no mood to change, or your leadership hasn’t yet been able to convince your group that it can no longer practice in the same expensive, antiquated model. As one academic chair said ruefully, at a recent meeting, “They’re like frogs being slowly boiled. They just don’t feel what’s happening.”

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