GOALIES AT THE PEARLY GATES
When you have surgery, do you care who administers your anesthetic?
An oft-repeated medical adage states: “anesthesia is 99% boredom and 1% panic.”
As an anesthesiologist who’s delivered over 50,000 hours of operating room care over 25 years, I can attest that the adage is true. Ninety-nine percent of the time, the anesthesia provider’s job requires vigilance during a patient’s stable progression of metronome heartbeats and regular breathing, but 1% of the time requires clear thinking and prompt action during moments of sheer panic. These stress-filled episodes of panic are unknown to the general public, yet represent ordeals that every anesthesia provider must rise above to protect their patients.
Webster’s Dictionary defines panic as “ an overwhelming feeling of fear and anxiety.” If you were to observe an anesthesiologist at work, you would see little or no evidence of overwhelming fear or anxiety. Even under dire emergencies, most anesthesia providers remain outwardly composed and efficient while they make the necessary diagnoses and apply the appropriate treatments. But anesthesiologists are human–no human can watch another human trying to die without feeling intense emotions. These emotions are fear and anxiety.
No field of medicine provides the stunning variety of anesthesia. Patients vary from neonates to centenarians, from laboring women to motor vehicle accident victims at three a.m., while surgeries vary from repair of a broken finger to the transplantation of a heart or a liver. Technologic advances have led surgeons to operate on older and sicker patients, and to attempt more complex surgeries than decades ago.
The operating room is an intense environment. Operating room medicine is pressure-packed for four reasons:
- Anesthetic drugs change the physiology of patients in profound ways.
- Surgeons do dangerous things to patients.
- Surgical patients have diseases. Some of these diseases are urgent or severe.
- Human beings make errors. This includes both surgeons and anesthesia providers.
Unbelievable events occur at unexpected times in operating rooms, and your anesthesia provider must keep you safe. He or she is in control of your airway, breathing, and circulation at every moment. Your anesthesia provider is your insurance policy against medical complications during surgery. Your anesthesia provider’s job is to play Goalie at the Pearly Gates, and keep you alive.
The individual administering your anesthesia can vary–your anesthesia provider may be:
- a medical doctor (an anesthesiologist),
- a certified registered nurse anesthetist (CRNA) or anesthesia assistant (AA) supervised by an anesthesiologist, or
- a CRNA working without anesthesiologist supervision.
In the United States, anesthesiologists personally administer 35% of the anesthetics. Anesthesia care teams, in which an anesthesiologist medically directs a team of AA’s or CRNA’s, administer 55% of the anesthetics. CRNA’s, working unsupervised, administer 10% of the anesthetics.
There are people who perceive anesthesia care to be so safe that it can be taken for granted. They are wrong. Anesthesia care is safest when a physician, a board-certified anesthesiologist, directs the anesthetic care. Published data shows that:
- Mortality rates after surgery are significantly lower when anesthesiologists direct anesthesia care.
- Failure-to-rescue rates (the rate of death after a complication) are significantly lower when anesthesiologists direct anesthesia care.
- Death rates and failure-to-rescue rates are significantly lower when board-certified anesthesiologists supervise anesthesia care, compared to when mid-career anesthesiologists who are not board-certified supervise anesthesia care.
“Failure-to-rescue” implies that the anesthesia provider wasn’t successful in preventing a 1% panic moment from turning into a death statistic. The phrase “failure-to-rescue” is a key theme of this book. Or more precisely, the phrase “successful rescue” is a key theme of this book. When unexpected events occur during surgery–the 1% panic moments–your anesthesia provider needs to make the correct diagnosis and apply the correct therapeutic intervention to successfully rescue you.
When you meet your anesthesia provider prior to surgery, you’re about to trust your life to a stranger. It matters who that stranger is. As a patient, do you have any control over who your anesthesia provider will be? If your surgery is an emergency at 2 a.m. when only one anesthesia provider is available, you will not. But for most surgeries, and all elective surgeries, you have choices.
Anesthesiologists must finish a minimum of 12 years of post-high school education–four years of college, four years of medical school, and four years of anesthesia internship and residency. Nurse anesthetists must finish a minimum of 7 or 8 years of post-high school education –four years of college, a minimum of one year of critical care nursing experience, and two to three years of anesthetist training. Anesthesia assistants must finish a minimum of 6 years of post-high school education–four years of college, and a 24-month program to obtain a Master’s degree as an anesthesia assistant.
Why would an individual choose to become an anesthesia provider? It’s rare for teenagers or college students to dream of themselves as anesthetists. Most popular television, movies, and fiction portray physicians in more conventional careers as surgeons, emergency room doctors, or in clinics. Only 4% of medical school graduates choose anesthesiology.
I believe that individuals who choose anesthesia for their medical career are individuals who love the adrenaline rush of acute medical care. Operating room anesthesia is a 180-degree turn from outpatient clinics, where practitioners take histories, order lab tests, write prescriptions for pills, and make appointments to see their patient weeks into the future. Instead of experiencing clinic visits over months or years, the anesthetic encounter is immediate care with immediate results. Instead of a clinic patient returning weeks later for a recheck, the anesthetic patient wakes up from their anesthetic, and is discharged to their home or their hospital bed within hours.
I had already completed a three-year residency in internal medicine before I began my years of anesthesia training. The diagnosis and treatment of complex medical patients appealed to me during internal medicine training, but I found the glacial pace of outpatient clinic care boring. When I worked along side anesthesiologists in the intensive care unit, I was wooed by their skills in placing breathing tubes, intravenous and intra-arterial catheters, and their apparent calmness no matter how ill any patient was. The world of acute care medicine is the world of airway, breathing, and circulation. No specialty mastered all three as completely as anesthesiologists did.
The beginning of specialty training in anesthesia brings both intimidating power and overwhelming challenge. For the first time in your life, your profession is to inject powerful medications into patients and watch them lose consciousness in seconds. Administering your first anesthetic is an unforgettable experience. One minute you are chatting with a patient, telling them to picture themselves relaxing on a beach in Hawaii, and the next minute you’ve rendered them unconscious and totally dependent on you to manage their airway, breathing, and circulation.
Moving from novice anesthesiologist trainee to experienced specialist requires hard work and patience. On the first day of my anesthesia residency, I was so green I didn’t even know which hoses connected my anesthesia gas machine to the patient. While learning the anesthesia profession, trainees must learn to endure the 99% boredom factor and glean their most valuable lessons during the 1% panic time. During my first week of training, after my patient was asleep with the breathing tube inserted and the anesthesia gases flowing, my faculty member, Dr. Gregory Ingham, said to me, “This procedure will take four hours.” He stood next to me for a minute or two in silence, then he said, “I hope you’re of a contemplative nature.”
Why would he say such a thing to a first-week trainee? I believe he said it because much of operating room anesthesia care is tedious vigilance over a stable situation. The anesthetist needs to cope with this fact, and hopefully even appreciate and enjoy the stability.
One week after my first exposure to Dr. Ingham, I was on call overnight in the hospital with him again. We had four consecutive emergency cases, all young healthy men with injuries suffered in motor vehicle or motorcycle accidents. Prior to the fourth case, at 2 a.m., I evaluated the patient and proposed my anesthetic plan. “Our patient is a healthy 25-year-old male except for his open femur fracture,” I said. “I thought we could do the anesthetic the same way we did the last three.”
Dr. Ingham nodded at me and sighed, “Richard, the patients are all different, but the anesthetics are all the same.”
Is this true? Why would he make a statement like this to an impressionable young trainee? There is a great deal of cynicism and battle fatigue in his comment, but a grain of truth. Patients are all different, and many anesthetics are similar, but not every anesthetic is identical. There are always choices for the anesthetist to make–crucial, life threatening decisions–every day, and on every case. Decisions are made before the surgery, during the stable phases of the anesthetic, and during the 1% of moments when the anesthetist’s mind is reeling.
Patients see none of this. Patients typically have ten minutes or less to meet their anesthesia provider. In the internal medicine clinic, patients are awake for 100% of their face-to-face time with their doctor, but before a surgery the anesthesiologist has only a brief encounter to gain their patient’s trust. In the internal medicine clinic, a large number of patients had chronic complaints that were difficult to cure: chronic pains, high blood pressure, obesity, or diabetes. The treatments were usually involved a prescription for pills. At the next office visit, the patient might feel better, but there was a significant chance that the patient would feel the same, or feel no better, or perhaps they have a new side-effect symptom from the pill you prescribed for them.
The anesthetic patient encounter is markedly different. Prior to the surgery, most patients are anxious but they treat their anesthesiologist with soaring respect. After the surgery, I find my patients are often gushing in their gratitude for the fact that I had delivered them safely back to consciousness. In contrast to my sometimes-disappointed medicine clinic patients, the anesthetic patients are so upbeat that they make me feel wonderful.
When I describe the elation of interacting with anesthesia patients, my best friend offers a simple explanation: “Of course your patients respect you before the surgery. You’re about to knock them unconscious. They’ll have no control and they’re completely dependent on you. They want you to like them. They want you to keep them alive.”
I believe that assessment is accurate. Every patient wants the same thing from their anesthesia provider. A successful, complication-free experience. And that’s what happens . . . almost every time.
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.
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