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Every anesthesia provider must learn to free-solo anesthesia early in his or her career. The 2018 movie Free Solo showcases Alex Honnold as he became the first person to free solo climb the 3000-feet high El Capitan wall of granite in Yosemite National Park without ropes or safety gear. This has been called the greatest feat in rock climbing history, and the movie is nominated for a 2019 Academy Award in the Feature Documentary category.
Believe it or not, but Free Solo could have been an anesthesiologist’s movie. How can that be? “Free-soloing” describes the most anxiety–producing event in every anesthesiologist’s life: the transition from anesthesia training when your faculty member is backing up your every move and every mistake, to the real world of anesthesia when you have to do scary cases alone without assistance.
During the dayshift, working alone is seldom an issue for any anesthesiologist. A typical hospital will have dozens of other anesthesia providers working in the same building. Within seconds or minutes, any anesthesiologist can be assisted or bailed out by a colleague.
Unlike Alex Honnold, the anesthesiologist is not putting their own life at risk—rather it is their patient who is at risk. The degree of risk is variable. For healthy patients undergoing elective surgery the anesthetic risks are minimal, and are similar to the risks of driving on a freeway in an automobile. For emergency surgeries, cardiac surgeries, chest surgeries, brain surgeries, or for anesthetics on patients with significant heart, lung, blood pressure, or airway problems, the risks of anesthesia are higher. The patient is totally dependent on their anesthesiologist to return them to consciousness safely.
Commercial aviation is sometimes compared to anesthesia practice. When commercial pilots take off in airliners, their passengers are totally dependent on the pilot to return them to the ground safely. But in commercial aviation there is one important difference: by law there must be a second pilot in the cockpit.
In anesthesia there is no guaranteed second anesthesiologist. There are multiple different models of anesthesia care. In an anesthesia care team, a physician anesthesiologist supervises up to four operating rooms and each operating room is staffed with a certified registered nurse anesthetist (CRNA). In a university hospital, a faculty member may supervise two operating rooms each with a resident anesthesiologist-in-training in attendance. In many hospital operating rooms, a solitary physician anesthesiologist attends to his or her patient alone. In seventeen “opt-out” states in America a solitary CRNA can attend to a patient without any physician anesthesiologist backup. Working alone may be less safe. A 2019 study from Europe reported an outcome advantage for anesthesiologist working in teams: The study showed that anesthesia given by teams of anesthesiologists and anesthesia nurses was associated with decreased 30-day postoperative mortality and a shorter length of stay when compared with solo anesthesiologists. There was no evidence for the specific cause of the decreased mortality.
Because of manpower necessities, there will never be a law mandating a second anesthesiologist for every surgery as there is in commercial aviation. There will always be emergencies at 2 a.m. or on weekend afternoons when all other anesthesiologists are elsewhere. As well, there are tens of thousands of freestanding surgery centers and office operating rooms where only one anesthesia professional is present.
Is there any data in the medical literature documenting that inexperienced anesthesia professionals have a greater incidence of adverse outcomes? Per Pubmed, there is no such publication. But there is no publication that denies the truth of this correlation. There is a paucity of data on the topic. The issue has not been rigorously studied in a scientific basis.
I review malpractice legal cases, and I can attest that inexperienced anesthesia personnel (who are less than board-certified physician anesthesiologists) are involved in many cases. I believe recent graduates are at particular risk when they work alone. In most cases with severe complications, the anesthesia professional (an MD or a CRNA) was managing the anesthetic alone until it was too late to save the patient.
During physician anesthesia training, a faculty member teaches, supervises, advises, and bails out each resident should there be a mishap. Following their three years of residency, a graduate is free to take a job as an attending anesthesiologist in any hospital system, multi-specialty clinic, or anesthesia group who will hire him or her. This is when the free-soloing begins.
Let me cite some examples of anesthesia free-soloing:
- The new graduate is on duty at 2 a.m., and a three-hundred-pound man arrives at the emergency room with the abdominal emergency of a dying, obstructed intestine. The surgeon decides the case is an emergency and cannot wait until morning. The typical anesthetic for this surgery is a rapid-sequence induction of intravenous general anesthesia, followed by the placement of a hollow breathing tube through the mouth into the patient’s windpipe. This sounds easy enough, except when it isn’t. Morbidly obese patients can be very difficult to intubate, and without a properly placed breathing tube these patients can be difficult to keep oxygenated. Five minutes without oxygen causes irreversible brain death. Sound scary? It is.
- The new graduate is on duty at 3 p.m. at a community hospital. A two-year-old girl arrives at the emergency room gasping for breath, crowing with each inspiration, febrile, drooling, and barely conscious. Both the emergency room physician and the anesthesiologist quickly make the diagnosis of acute epiglottitis, a rare bacterial infection which causes the epiglottis (the flap which covers the windpipe when you swallow) to become inflamed and swollen. This causes a severe obstruction during each inhaled breath. The patient needs a breathing tube within minutes, before the swollen epiglottis cuts off all passage for air inflow into the lungs. I had this very case during my first year in private practice. I’d read about the proper management, but I’d never seen acute epiglottitis myself. The appropriate treatment is to bring the patient to the operating room urgently, and to staff an experienced head and neck surgeon at the bedside. The anesthesiologist’s job is to induce sleep with an inhaled anesthetic (sevoflurane) via a mask, while carefully supporting the airway and facilitating the passage of oxygen and anesthesia gas in and out of the lungs until the patient falls asleep. Once the patient is asleep, a physician or nurse must place an IV catheter in the patient’s arm, and then the anesthesiologist must insert a lighted scope into the patient’s mouth, locate the swollen epiglottis and the opening to the windpipe below it, and insert a tiny hollow plastic breathing tube into the windpipe. If anything goes wrong and the breathing tube cannot be inserted before the child turns blue, the surgeon must immediately slice into the child’s neck and insert a breathing tube through the skin. Once again, five minutes without oxygen causes irreversible brain damage. Sound scary? It is.
- The new graduate is on duty alone at a dental office, anesthetizing a 17-year-old male for wisdom teeth removal. After the induction of general anesthesia but before the beginning of surgery, the anesthesiologist administers a requested dose of intravenous antibiotic. Minutes later, the patient’s blood pressure drops from 120/80 to 60/30, the heart rate climbs from 80 to 160 beats per minute, and the normal lung sounds convert to tight wheezes. Hopefully the anesthesiologist will make the correct diagnosis of an anaphylactic allergic reaction—most likely due to the antibiotic. The effective treatment requires perfect management of the patient’s airway, breathing, and circulation. The specific treatment for anaphylaxis requires intravenous injection of epinephrine (adrenaline). A misdiagnosis leading to the omission of epinephrine can be fatal. If the blood pressure remains low and the lungs continue to deteriorate, there will be a lack of oxygen delivery to the brain. Once again, five minutes without oxygen causes irreversible brain damage. Sound scary? It is.
What can be done to make free-soloing safer for patients? In my opinion, the best safety ropes are these:
- Most hospitals have an emergency room physician on duty at all hours. These MDs are multi-talented and have the acute care skills necessary to assist an anesthesiologist in an emergency. Rather than waiting until a patient has a cardiac arrest or until an airway is lost and the patient’s brain is losing oxygen, an anesthesia professional can consult the ER doctor in advance, e.g. requesting them to assist with a difficult induction of anesthesia on a morbidly obese adult or with a child with a difficult airway.
- Even if no experienced anesthesiologist is present in the hospital, there is always an experienced physician anesthesiologist colleague available on the other end of a phone call. Young or inexperienced anesthesia professionals can telephone senior anesthesiologists prior to the anesthetic, whenever a situation arises in which they are doubtful, insecure, or uncomfortable. It’s difficult to admit a lack of confidence, but it’s better to do this than to review a terrible complication with the senior anesthesiologist the next day, like two firefighters gazing over the burned basement remains of a previously preserved house.
- Most American anesthesia training programs are now utilizing simulation training facilities to prepare residents for severe acute care scenarios. A simulator lab has a surrogate patient and a full battery of vital sign monitors under the control of a teacher. The teacher can dial in a variety of emergencies and observe the pupil’s response to the emergencies. Feedback is given afterward regarding observed errors and any needed improvements in management. If a young physician anesthesiologist has faced emergencies in the simulator, we believe the anesthesiologist will be better prepared to free-solo following their training.
- The Stanford Anesthesiology department authored the Stanford Cognitive Aid Emergency Manual, a booklet of itemized recipes and checklists for all common dire emergencies one might see in an operating room. A PDF of this booklet is available for free of charge download here. Using the Stanford Cognitive Aid Emergency Manual in the operating room will help prevent medical errors, even by inexperienced anesthesia professionals.
- Whenever possible, solo anesthesiologists should have already passed the American Board of Anesthesiologists written and oral examinations, and therefore be board-certified. It’s a fact that one can practice anesthesiology in the United States without being board certified, but the ABA oral examination forces graduates to answer difficult questions in the pressure cooker of an oral exam room. Board-certified anesthesiologists will be better prepared for the pressure cooker of an operating room emergency as well.
If you’re a patient, should you worry about your anesthetist free-soloing during your surgery?
Let me reassure you. If you’re having an elective surgery in a hospital in the daytime, there are usually multiple backup anesthesia providers to assist with any problems. But for emergencies in the middle of the night, on weekends, or at freestanding surgical facilities with only one anesthesiologist present, your anesthesia care and outcome will be solely dependent on the skills, training, and experience of the solitary individual who is attending to you.
I’ve stood at the bottom of El Capitan in Yosemite National Park and looked upward at the vertical granite face with awe. I could never climb El Capitan, with or without ropes. I respect what Alex Honnold did at the highest level. He is brave beyond measure and he was willing to put his life on the line. Anesthesiologists, particularly junior anesthesiologists, must free-solo as well. No Hollywood cameras will be rolling, but the adrenaline will be pumping through their veins just as if they themselves were climbing El Capitan.
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