Latest posts by the anesthesia consultant (see all)
- THE ELECTRIC CHAIR AND ANESTHESIOLOGY - 21 Aug 2019
- DO DOCTORS EVER RIDE IN AMBULANCES? - 11 Jul 2019
- REGARDING THE FRENCH ANESTHESIOLOGIST ACCUSED OF MURDER - 1 Jul 2019
Do doctors ever ride in ambulances? Ambulances are a territory usually staffed by Emergency Medical Technician (EMT) personnel, but yes, in certain emergencies doctors do ride in ambulances.
In the process of doing 30,000 anesthetics, I’ve taken several rides in the back of an ambulance with my patients. Why? Sixty-six percent of surgeries in the United States take place as an outpatient, and many of these surgeries are performed at freestanding facilities distant from hospitals. When a patient decompensates emergently at a freestanding ambulatory surgery center or in an operating room at a doctor’s office, the facility will call for an ambulance staffed with EMT personnel. If the patient is unstable, a physician, usually an anesthesiologist, will need to accompany the patient and the EMTs to the hospital emergency room.
The following are examples of cases in which I or my colleagues have ridden in ambulances from freestanding surgery centers to the Stanford Emergency Room and Stanford Hospital in Palo Alto, California:
- A 3-year-old girl developed negative pressure pulmonary edema with plummeting pulse oximetry readings 10 minutes after a tonsillectomy. Her breathing tube had been removed, but she developed upper airway obstruction in the Post Anesthesia Care Unit (PACU) and needed urgent reintubation. She was extubated one hour later at the surgery center after treatment with diuretic, oxygen, and ventilation via the tube. She was then transferred to the hospital for overnight observation of her airway, pulmonary function, and oxygenation. The duty in the ambulance included monitoring her oxygenation, her airway and her breathing. The presence of an anesthesiologist was reassuring to the stunned parents who had no expectation of a complication after a common surgery such as a tonsillectomy. The patient was discharged the following day without further complication.
- A 75-year-old female underwent lateral epicondylitis release surgery on her right elbow, and developed acute pulmonary edema with failing oxygen saturation levels at the conclusion of surgery. The patient had a past history of aortic stenosis, and had her aortic valve replaced with a small metal valve two years earlier. She was active, although she did experience mild shortness of breath on walking stairs. She was obese with a BMI=35. She received a general anesthetic with an endotracheal tube. The surgery was simple and the surgical duration was only 17 minutes. When the anesthetics were discontinued at the end of surgery, her blood pressure climbed to markedly high levels, and her heart failed to pump effectively against the elevated blood pressure. Pulmonary edema fluid filled her lungs and filled the hoses of the anesthesia machine. Her oxygenation returned to normal after titrating her BP down with a nitroprusside drip, and her blood pressure needed to be monitored continuously by an arterial line inserted into her radial artery at the wrist. The duty in the ambulance included ventilating the patient via the Ambu bag, keeping the patient sedated, watching the arterial line pressure continuously, and titrating the level of the vasodilating nitroprusside infusion. She remained intubated overnight in the hospital and was extubated the next day. She survived without any further complication and did not have a myocardial infarction.
- A healthy 45-year-old woman developed acute hypotension 6 hours following a laparoscopic hysterectomy. The surgery was done in a small community hospital where there was no ICU, blood bank, or emergency room. The patient had multiple low-normal blood pressure readings over the first 5 hours postoperatively, and was being observed by the nursing staff. At hour 6 her blood pressure dropped to a dangerously low level and her hematocrit level on a portable device came back as 9.9%, indicative of a severe acute anemia. She was transferred urgently to the hospital. The duty in the ambulance included resuscitation with IV fluids, and observation of her airway and breathing as her level of consciousness dropped. She required repeat surgery at the hospital to control the intraabdominal bleeding, as well as preoperative transfusion to treat her anemia and hypovolemic shock.
These three cases are examples of surgical patients who became acutely ill miles from the nearest hospital. Each case illustrates how a failure of airway, breathing, or circulation can lead to an emergency. The problem in the first case was airway obstruction leading to pulmonary edema. The problem in the second case was lungs filled with fluid which made normal breathing impossible. The problem in the third case was bleeding which caused the normal circulation of blood within the body to be inadequate.
Why did an anesthesiologist travel with each patient?
- Each patient was extremely sick and required acute monitoring and treatment, and medical decisions needed to be made during the trip to the hospital. EMTs are trained in resuscitation, but EMT training is only a fraction of anesthesiologist training. Having the anesthesiologist who was already resuscitating the patient continue to care for the patient en route to the hospital was the wisest course.
- Acute medical emergencies are defined by resuscitation of Airway-Breathing-Circulation. Anesthesiologists are the physicians with the highest level of airway skills, as well they are experts in acute resuscitation. If any physician is to travel with the patient, an anesthesiologist is the wisest choice to manage Airway-Breathing-Circulation in ongoing emergencies.
- Medical-legal risk is minimized if the most highly trained physician involved in the case continues to manage the case. The handoff or transfer of medical care from one practitioner to another is a high risk time for errors. The anesthesiologist is responsible for the safety and care of his or her patient, and the highest continuity of care occurs when the anesthesiologist who managed the emergency attends to the patient during the transfer to the hospital.
I’ve been the Medical Director at a freestanding surgery center near Stanford for the past 17 years. Surgery centers strive to minimize the potential of emergencies in outpatient surgeries. Medical Directors work to limit the types of cases performed in a freestanding surgery center. This includes avoiding procedures that cause major pain, bleeding, or disruption of physiology. Typical surgeries performed in freestanding centers include:
- Arthroscopic orthopedic surgeries
- Simple ear nose and throat surgeries
- GI endoscopies and colonoscopies
- Simple general surgery procedures
- Simple ophthalmologic surgeries
- Plastic surgeries
Surgery centers also strive to operate on healthier patients who lack major comorbidities. Surgery centers are reluctant to approve general anesthesia in a freestanding outpatient setting to patients who have:
- Severe sleep apnea
- Severe cardiac problems such as shortness of breath or ongoing chest pain
- Severe morbid obesity or super-morbid obesity
- Renal dialysis
- Severe abnormal airways
- Markedly abnormal blood pressures, heart rates, or blood oxygen levels
Regarding ambulance rides, no one is going to advocate that MDs take over EMTs roles regarding riding in ambulances. But when surgery or anesthesia leads to an acute event at a site distant from a hospital, the anesthesiologist involved in that patient’s care is responsible for that patient’s safety and for the ongoing care and resuscitation. The anesthesiologist will be riding in the ambulance and doing what anesthesiologists routinely do–managing Airway-Breathing-Circulation.
If any anesthesia professionals have stories regarding their own emergency ambulance rides resuscitating patients, I invite you to share them with my readers.
The most popular posts for laypeople on The Anesthesia Consultant include:
The most popular posts for anesthesia professionals on The Anesthesia Consultant include: