Your 4-year-old son Jake snores and has enlarged tonsils. Your pediatrician refers you to an ear, nose, and throat (ENT) specialist. The ENT specialist recommends tonsillectomy, and schedules Jake for tonsillectomy for next Friday morning. Who will do Jake’s anesthesia, and how will the anesthesia care be done?
Jake may or may not be diagnosed with Obstructive Sleep Apnea (OSA), based on his history of snoring. Most children who snore and have enlarged tonsils are not subjected to a formal sleep study. In a formal sleep study, doctors attach monitors such as pulse oximeters and apnea monitors to the child during a night’s sleep, to determine how often the child stops breathing during sleep and how low the oxygen level in his or her arterial blood drops during disordered sleep. A sleep study is commonly done for adults with suspected OSA, but not commonly ordered in children.
The decision to excise tonsils in pediatric patients is a clinical decision, based on the judgment of the pediatrician and ENT surgeon. The surgery can be scheduled at a community hospital, a university hospital, a pediatric hospital, an ambulatory surgery center, or a freestanding ambulatory surgery center. The nature of the anesthesia personnel can vary significantly depending on which type of facility the surgery is scheduled at.
In a community hospital, the anesthesia staff will be medical doctors (anesthesiologists), and/or nurse anesthetists (CRNA’s). The anesthesiologists may or may not be pediatric specialists, but all anesthesiologists receive training in anesthetizing children. Most likely, the ENT surgeon operates with an anesthesia team he or she is comfortable with, and this anesthesia team is comfortable anesthetizing children for a routine, elective surgery like tonsillectomy. At a community hospital, it is possible but unlikely that the anesthesiologist will have completed extra years of training in pediatric anesthesia called a pediatric anesthesia fellowship.
In a university hospital, the anesthesia staff will include anesthesiologist faculty and also anesthesiologist residents and fellows who are in training. The anesthesia care is directed or performed by a faculty member. The actual hands-on anesthesia care, such as the placement of breathing tubes and IV catheters, is usually done by the residents and fellows, who are in the midst of their training. An advantage of university hospitals is that pediatric anesthesia specialists are plentiful. A disadvantage is that the anesthesia care is usually done by the trainee anesthesiologists who are supervised by these specialists. At times, one faculty anesthesiologist may be supervising trainee anesthesiologists in two separate operating rooms for two separate surgeries concurrently.
In a pediatric hospital, the anesthesia care will be done by specialty pediatric anesthesiologists. However, if the pediatric hospital is a university pediatric hospital, all the analysis in the preceding paragraph pertaining to university hospitals will apply.
An ambulatory surgery center (ASC) is a set of surgical suites that is designed to take care of outpatient surgeries, and designed to send the patient home directly from the ASC after recovery from surgery and anesthesia. Most tonsillectomies are done as outpatient surgeries, and therefore many tonsillectomy patients are operated on in an ASC. If the ASC is located inside a hospital, the anesthesia care will follow the analysis of community, university, and pediatric hospitals as discussed in the paragraphs above. Many ASC’s are freestanding–that is, they are not on site in a hospital. Many are located miles away from hospitals. It is commonplace in the United States for tonsillectomies to be safely done in freestanding ASC’s. The anesthesia care in most freestanding ASC’s will be anesthesiologists and/or nurse anesthetists, and once again the ENT surgeon will select an anesthesia provider he or she feels will provide safe care for his patient.
Some anesthesia teams prefer to meet and interview their patients days before surgery. For a routine surgery such as tonsillectomy, it is common for the family to not meet the anesthesiologist until the day of surgery shortly before the procedure. Some anesthesiologists will telephone the parent(s) the night before surgery to interview them and provide a preview of what to expect on the day of surgery.
The actual anesthesia care will typically follow this scenario: Most practitioners will premedicate the child with oral midazolam (Versed) 20 minutes before the surgery. This medication will make the child sleepy and relaxed, and calm the patient through the time when they separate from their parent(s). Most facilities in the United States will not allow parents into the operating room. Inside the operating room, the anesthesiologist will apply standard monitors of oxygen level, pulse, and blood pressure, and induce anesthesia by having the child breath the anesthesia gas sevoflurane through a mask. Once the child is asleep, the anesthesiologist will place an IV in the child’s arm and a breathing tube in the child’s airway. After the surgery is completed, the anesthesiologist will discontinue the anesthetics, awaken the child, and remove the breathing tube. He or she will accompany the child to the Post Anesthesia Care Unit (PACU) and turn over the care of the child to a nurse there.
Is it safer if your child has a pediatric anesthesiologist, rather than a general practitioner anesthesiologist who takes care of both adults and children? It depends. It’s important to ask how often the practitioner anesthetizes children. Someone who rarely anesthetizes a child under 6 years of age will be less comfortable with such a case, and may be less skillful in dealing with a complication or emergency should one occur.
Is it safer if your child has a fully-trained anesthesiologist rather than an anesthesia trainee/faculty team such as at a university hospital program? Once again, it depends. It depends on how much of the care is done by the trainee, and how intensive the faculty supervision is, as compared to an alternative facility where a fully-trained anesthesiologist stays present throughout the entire surgery.
At a community hospital or ASC, it is uncommon to have multiple specialist anesthesiologists on call each day, e.g. one for pediatrics, one for cardiac cases, one for trauma, one for obstetrics, and others for the general operating rooms. Instead, general anesthesia practitioners cover many or all specialties. If an anesthesiologist is not comfortable with an individual case, they can seek out a better trained anesthesiologist to cover the case, if such an anesthesiologist is available. The trend for having a specialist anesthesiologist for every type of case is a difficult one to staff. The goal at a community hospital is to assure that the standard of anesthesia care can be met with the physicians who are on staff and available.
In my opinion, neonates and young infants should be cared for by anesthesiologists with specialized pediatric training. Whether specialized training should be mandated for children older than infants is debatable. Policies to define a minimum age limit for patients of general anesthesiologists may be a hot topic in the future.
In the meantime, I recommend you ask your child’s anesthetist: 1) who is doing the actual anesthesia care today, a fully-trained anesthesia doctor, a doctor-in-training, or a nurse anesthetist? 2) how much training does the anesthetist have with children Jake’s age? and 3) how many children of Jake’s age have they anesthetized for a similar surgery in the past 12 months? If you are uncomfortable with any of the answers, find another place for Jake to have his surgery.
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: