Clinical Case for Discussion: You, your spouse, and your 5-year-old son are vacationing in Montana when your son develops acute abdominal pain and fever. You take him to the largest medical center around, the community hospital in a town with a population of 20,000. The surgeon there makes the diagnosis of an acute abdomen, and plans on operating. You meet the anesthesia provider, and it is an unsupervised certified registered nurse anesthetist (CRNA). What do you do?
Discussion: Circa 1985, one of my anesthesia Stanford mentors told me this: “If you’re on vacation in some rural place like Montana, and you need emergency surgery, let the anesthetist do the case whatever way he usually does it–if the only way he knows how to do things is open drop ether technique, you need to let him do it the way he knows. It’s not the time to educate him into trying something new and different.”
Now you are in a rural hospital with a sick kid, and you feel nervous. You ask the CRNA about his clinical experience, and he tells you he’s been out of training for 10 years, and has anesthetized hundreds of children without a single complication.
Your spouse (a non-medical professional) speaks up first, declaring that you are an anesthesiologist, and that he or she (the spouse) is adamantly opposed to the child having an anesthetic by a unsupervised nurse. Your spouse asks how far it is to the nearest major medical center that would have pediatric anesthesia care supervised or performed by an MD? The answer: a two-and-a-half hour drive. Your child is moaning in the bed in front of you, and you realize that delaying the surgery for hours is a bad idea.
Your spouse tells you he/she wants you to do the anesthetic. There are several problems with this solution. Number one: you do not have a state license in Montana. Number two: the hospital has a policy that family members are not allowed into the operating rooms during surgery. Number three: you have always been advised by your mentors and peers that physicians who take anesthetize or operate on their own family members have a difficult time being either objective or professional if some unfortunate complication arise.
You pull the surgeon aside and ask his views on the CRNA and the pediatric anesthetic assignment. The surgeon reports that he has been working with this CRNA for 12 months, but has yet to see the CRNA anesthetize anyone under the age of 18 for him. He confirms that on this weekend evening, there are no other anesthesia professionals within sixty miles.
Your son continues to moan. Your spouse is pacing, and continues to fret about the CRNA not touching the child. Your head is spinning. What do you do?
As a father and an anesthesiologist, on 4 occasions I have handed one of my kids over to another anesthesiologist for surgery. Each time I selected the anesthesiologist myself, I knew the anesthesiologist well, and trusted their skills under any circumstances. Each surgery went well, but I can attest that every parent is on edge until they see their child awake and well after the conclusion of the surgery. You, as a parent, will feel intensely protective of your child.
You realize that surgical emergencies likely occur somewhere in Montana every day, and that unsupervised nurse anesthetists are conducting many of these anesthetics. You haven’t heard or read of an epidemic of anesthetic disasters in “opt out” states, where governors have decided that CRNA’s can conduct anesthesia without MD supervision.
You reason that your son is probably on safe ground, but . . . if something went wrong, you’d feel guilty for not being more involved. You know you’d feel uncomfortable sitting in the waiting room while the surgeon and CRNA do their best work in the OR. Can you convince the surgeon and CRNA that you want to be in the OR with them as an observer, although this is against hospital policy? Can you convince them to telephone the Chief of Staff to make an exception in this one case?
What if the story played out as follows: You call the Chief of Staff, you present your request is a cordial fashion, she empathizes, and allows you to observe in the OR.
You watch the anesthetic induction proceed uneventfully. After intubation, the anesthetist inserts an oral gastric tube to suction out the stomach. The surgery begins, and the diagnosis is a perforated appendix. The surgeon performs the required surgery. On anesthetic emergence, the CRNA untapes the endotracheal tube before your son’s eyes open, and begins letting air out of the cuff with a syringe. Your heart rate quickens, and you blurt out, “Can you wait until he’s more awake before extubating him?” The anesthetist answers, “I like to extubate deep, so there is less bucking. I suctioned the oral gastric tube, so I know his stomach is empty now.” While the two of you are debating, your son wretches forcefully and vomits a large volume of bilious fluid. The good news is that the endotracheal tube was still in place, with the cuff inflated. The good news is that none of the vomitus was aspirated. Flustered, the anesthetist suctions out the mouth, and waits until the patient is wide awake before extubating him. Minutes later, your son is awake and safe, but your hands are still shaking.
Fiction? Sure, but the issue and question is whether or not unsupervised CRNA anesthesia is a good idea. If your son had aspirated due to poor anesthetic judgment, would that event have shown up as a vital statistic anywhere? I doubt it.
J H Silber’s landmark study from the University of Pennsylvania (Anesthesiologist direction and patient outcomes, Anesthesiology. 2000 Jul;93(1):152-63) documented that both 30-day mortality and failure-to-rescue rates were lower when anesthesia care was supervised by anesthesiologists, as opposed to anesthesia care by unsupervised nurse anesthetists. This study was widely discussed. The CRNA community dismissed the conclusions, citing that it was a retrospective study. In a letter to the editor published in Anesthesiology, Dr. Bruce Kleinman wrote regarding the Silber data, “this study could not and does not address the key issue: can CRNAs practice independently? In fact, the negative outcomes in this retrospective study may be related to the medical direction of nonanesthesiologists and may not be related in any way to the practice of CRNAs per se.” (Anesthesiology: April 2001 – Volume 94 – Issue 4 – p 713)
Governor Schwarzenegger stunned California anesthesiologists in July 2009 by signing a document opting California out of the requirement for CRNA’s to be supervised by an MD. An important conflict is the fact that California law rules that an MD must supervise the medical practice of CRNA’s. The outcome for California is still undetermined, but the threat of CRNA’s replacing larger subsets of anesthesiologist’s work in future years is a crucial and daunting issue that all of us will follow with interest and intensity. Your delegates and lobbyists in the California Society of Anesthesiologists and the American Society of Anesthesiologists are working on the issue of unsupervised CRNA anesthesia care. It’s a battle that needs to be fought, for the patients and their families, as much as for the careers of present and future anesthesiologists.
Back to the Clinical Case–if you are vacationing in Yellowstone or Glacier National Parks next summer, hopefully your family will stay out of the operating room and you never have the ponder any of these problems.
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below: