FREE SOLO

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

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.

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FREE SOLO movie poster 2018

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.

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Let me cite some examples of anesthesia free-soloing:

  1. 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.
  2. 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.
  3. 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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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THE TOP 10 MOST STRESSFUL JOBS IN AMERICA versus THE TOP 10 MOST STRESSFUL SITUATIONS IN ANESTHESIOLOGY PRACTICE

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Anesthesia has been described as 99% boredom and 1% panic. Is anesthesiology one of America’s most stressful jobs? Not according to prominent Internet media sources.

Careercast.com listed the Top 10 Most Stressful Jobs in America in 2015, and those jobs were:

  1. Firefighter
  2. Enlisted Military Personnel
  3. Military General
  4. Airline Pilot
  5. Police Officer
  6. Actor
  7. Broadcaster
  8. Event Coordinator
  9. Photo Journalist
  10. Newspaper Reporter.

ABCnews.go.com listed the Top 10 Most Stressful Jobs in America in 2014, and those jobs were:

  1. Working Parents
  2. Deployed Military Personnel
  3. Police Officer
  4. Teacher
  5. Medical Professionals (The article highlighted surgeons for their need to constantly focus, psychiatrists for their need to intently listen, dentists for being on their feet all day, and interns for their lack of sleep).
  6. Emergency Personnel (The article highlighted firefighters and emergency medical technicians).
  7. Pilots and Air Traffic Controllers
  8. Newspaper Reporters
  9. Corporate Executive
  10. Miner

Salary.com listed the Top 10 Most Stressful Jobs in America, and those jobs were:

  1. Military Personnel
  2. Surgeon
  3. Firefighter
  4. Commercial Airline Pilot
  5. Police Officer
  6. Registered Nurse in an Emergency Room
  7. Emergency Dispatch Personnel
  8. Newspaper Reporter
  9. Social Worker
  10. Teacher

“Anesthesiologist” is absent from every list. This is a public relations failure for our specialty. The challenges and stressors anesthesia professionals face every day are seemingly unknown to the media and the populace.

I’ll admit there are pressures involved with being a taxi driver, a news reporter, a photo journalist, an events coordinator, or a public relations executive. Being a working parent is a challenge, although in Northern California where I live millions of adults are working parents because both husbands and wives have to work to pay hefty Bay Area living expenses. But none of these jobs involve the risk and possibility of their clients dying each and every day.

Every surgical patient requires the utmost in vigilance from their physician anesthesiologist in order to prevent life-threatening disturbances of Airway-Breathing-Circulation. The public perceives surgeons as holding patients’ life in their skilled hands, and they are correct. But most surgeons spend the majority of their work time in clinics and on hospital wards attending to pre-operative and post-operative patients. On the 1 – 3 days a week most surgeons spend operating, they are joined in the operating room by anesthesiologists who attend to surgical patients’ lives every day.

Surgeons in trauma, cardiac, neurologic, abdominal, chest, vascular, pediatric, or microsurgery specialties have intense pressure during their hours in the operating room, but each time they don their sterile gloves and hold a scalpel, an anesthesiologist is there working with them.

What follows is my own personal “Top 10 Most Stressful” list, a list of the Most Stressful Anesthesia Situations based on my thirty years of anesthesia practice. Anesthesia practice has been described as 99% boredom and 1% panic, (http://theanesthesiaconsultant.com/is-anesthesia-99-boredom-and-1-panic) and the 1% panic times can be frightening. Read through this list. I believe it will convince you that the job of an anesthesiologist deserves to be on everyone’s Top 10 Most Stressful Jobs list.

TOP 10 MOST STRESSFUL SITUATIONS IN AN ANESTHESIOLOGIST’S JOB

  1. Emergency general anesthesia in a morbidly obese patient. Picture a 350-pound man with a bellyful of beer and pizza, who needs an emergency general anesthetic. When a patient with a Body Mass Index (BMI) > 40 needs to be put to sleep urgently, it’s dangerous. Oxygen reserves are low in a morbidly obese patient, and if the anesthesiologist is unable to place an endotracheal tube safely, there’s a genuine risk of hypoxic brain damage or cardiac arrest within minutes.
  1. Liver transplantation. Picture a patient ill with cirrhosis and end-stage-liver-failure who needs a complex 10 to 20-hour-long abdominal surgery, a surgery whichfrequently demands massive transfusion equal to one blood volume (5 liters) or more. These cases are maximally stressful in both intensity and duration.
  1. An emergency Cesarean section under general anesthesia in the wee hours of the morning. Picture a 3 a.m. emergency general anesthetic on a pregnant woman whose fetus is having cardiac decelerations (a risky slow heart rate pattern). The anesthesiologist needs to get the woman to sleep within minutes so the baby can be delivered by the obstetrician. Pregnant women have full stomachs and can have difficult airway because of weight changes and body habitus changes of term pregnancy. If the anesthesiologist mismanages the airway during emergency induction of anesthesia, both the mother and the child’s life are in danger from lack of oxygen within minutes.
  1. Acute epiglottitis in a child. Picture an 11-month-old boy crowing for every strained breath because the infection of acute epiglottis has caused swelling of his upper airway passage. These children arrive at the Emergency Room lethargic, gasping for breath, and turning blue. Safe anesthetic management requires urgently anesthetizing the child with inhaled sevoflurane, inserting an intravenous line, and placing a tracheal breathing tube before the child’s airway shuts down. A head and neck surgeon must be present to perform an emergency tracheostomy should the airway management by the anesthesiologist fails.
  1. Any emergency surgery on a newborn baby. Picture a one-pound newborn premature infant with a congenital defect that is a threat to his or her life. This defect may be a diaphragmatic hernia (the child’s intestines are herniated into the chest), an omphalocele (the child’s intestines are protruding from the anterior abdominal wall, spina bifida (a sac connected to the child’s spinal cord canal is open the air through a defect in the back), or a severe congenital heart disorder such as a transposition of the great vessels (the major blood vessels: the aorta, the vena cavas and the pulmonary artery, are attached to the heart in the wrong locations). Anesthetizing a patient this small for surgeries this big requires the utmost in skill and nerve.
  1. Acute anaphylaxis. Picture a patient’s blood pressure suddenly dropping to near zero and their airway passages constricting in a severe acute asthmatic attack. Immediate diagnosis is paramount, because intravenous epinephrine therapy will reverse most anaphylactic insults, and no other treatment is likely to be effective.
  1. Malignant Hyperthermia. Picture an emergency where an anesthetized patient’s temperature unexpectedly rises to over 104 degrees Fahrenheit due to hypermetabolic acidotic chemical changes in the patient’s skeletal muscles. The disease requires rapid diagnosis and treatment with the antidote dantrolene, as well as acute medical measures to decrease temperature, acidosis, and high blood potassium levels which can otherwise be fatal.
  1. An intraoperative myocardial infarction (heart attack). Picture an anesthetized 60-year-old patient who develops a sudden drop in their blood pressure due to failed pumping of their heart. This can occur because of an occluded coronary artery or a severe abnormal rhythm of their heart. Otherwise known as cardiogenic shock, this syndrome can lead to cardiac arrest unless the heart is supported with the precise correct amount of medications to increase the pumping function or improve the arrhythmia.
  1. Any massive trauma patient with injuries both to their airway and to their major vessels. Picture a motorcycle accident victim with a bloodied, smashed-in face and a blood pressure of near zero due to hemorrhage. The placement of an airway tube can be extremely difficult because of the altered anatomy of the head and neck, and the management of the circulation is urgent because of the empty heart and great vessels secondary to acute bleeding.
  1. The syndrome of “can’t intubate, can’t ventilate.” You’re the anesthesiologist. Picture any patient to whom you’ve just induced anesthesia, and your attempt to insert the tracheal breathing tube is impossible due to the patient’s anatomy. Next you attempt to ventilate oxygen into the patient’s lungs via a mask and bag, and you discover that you are unable to ventilate any adequate amount of oxygen. The beep-beep-beep of the oxygen saturation monitor is registering progressively lower notes, and the oximeter alarms as the patient’s oxygen saturation drops below 90%. If repeated attempts at intubation and ventilation fail and the patient’s oxygen saturation drops below 85-90% and remains low, the patient will incur hypoxic brain damage within 3 – 5 minutes. This situation is the worst-case scenario that every anesthesia professional must avoid if possible. If it does occur, the anesthesia professional or a surgical colleague must be ready and prepared to insert a surgical airway (cricothyroidotomy or tracheostomy) into the neck before enough time passes to cause irreversible brain damage.

So goes my list of Top 10 List of Stressful Anesthesia situations. If you’re an anesthesia professional, what other cases would you include on the list? Which cases would you delete? How many of these situations have you personally experienced?

This Top 10 Stressful Situations in Anesthesiology list should be enough to convince you that “Anesthesiologist” belongs on everyone’s Most Stressful Jobs list.

I would reassemble the Top 10 List of Most Stressful Jobs to be as follows:

The Anesthesia Consultant’s List of Top 10 Most Stressful Jobs

  1. Enlisted military personnel
  2. Military general in wartime
  3. Police Officer
  4. Firefighter
  5. Anesthesiologist
  6. Surgeon
  7. Emergency Room Physician
  8. Airline Pilot
  9. Air Traffic Controller
  10. Corporate Chief Executive Officer