The anesthesia consultant

The most popular posts for anesthesia professionals on The Anesthesia Consultant include:

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

OBAMACARE AND ANESTHESIA

14 Feb 20141 Nov 2018THE ANESTHESIA CONSULTANT 1 Comment

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How Long Will It Take To Wake Up From General Anesthesia?

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Latest posts by THE ANESTHESIA CONSULTANT (see all)

WRITING MEDICAL FICTION - 6 Dec 2023
HIGH FLOW NASAL OXYGEN:AN ANESTHESIA GAME-CHANGER - 15 Nov 2023
STANFORD EMERGENCY MANUAL POCKET VERSION - 28 Sep 2023

Key questions in our specialty in 2014 related to Obamacare and anesthesia. This article was originally published in 2014, when Barack Obama was the President of the United States. A key question in our specialty at that time was “How will ObamaCare affect anesthesiology?” The following essay represents my thoughts as of 2014, prior to the Trump presidency.

I don’t have a crystal ball, but based on what I’ve read, what I’ve observed, and what I’m hearing from other physicians, these are my predictions on how ObamaCare will change anesthesia practice in the United States:

There will be more patients waiting for surgery. Millions of new patients will have ObamaCare cards and coverage. A flawed premise of ObamaCare is that a system can cover more patients and yet spend less money.
Reimbursement rates will be lower. How many anesthesiologists will sign up for Medicaid or Medicare-equivalent rates to care for patients? Large organizations such as university hospitals, Kaiser, Sutter, and other HMO-types will likely sign up for the best rate they can negotiate. As a result, their physicians will have increased patient numbers and lower reimbursement for their time. The insurance plans that patients purchase will have higher deductibles, and most patients will have to pay more out of pocket for their surgery and anesthesia. This will lead to patients delaying surgery, and shopping around to find the best value for their healthcare dollar.
Less old anesthesiologists. Older anesthesiologists will retire early rather than work for markedly reduced pay.
Less young anesthesiologists. The pipeline of new, young anesthesiologists will slow. Young men and women are unlikely to sign up for 4 years of medical school, 4 – 6 years of residency and fellowship, and an average of $150,000 of student debt if their income incentives are severely cut by ObamaCare.
More certified nurse anesthetists (CRNAs). It seems apparent that ObamaCare is interested in employing cheaper providers of medical services. CRNAs will command lower salaries than anesthesiologists. The premise to be tested is whether CRNAs can provide the same care for less money. Expect to see wider use of anesthesia care teams and of independent CRNA practice. Expect the overall quality of anesthesia care to change as more CRNAs and less M.D.’s are employed.
A two-tiered system. Anesthesiologists who have a choice will not sign up for reduced ObamaCare rates of reimbursement. Surgeons who have a choice will not sign up for reduced ObamaCare reimbursement. Expect a second tier of private pay medical care to exist, where patients will choose non-ObamaCare M.D.’s of their choice, and will pay these physicians whatever the physicians charge. This tier will provide higher service and shorter waiting times before surgery is performed. This tier will likely be populated by some of the finest surgeons–surgeons are unwilling to work for decreased wages. A subset of anesthesiologists will work in this upper tier of medical care, and these anesthesiologists will earn higher wages as a result.
Will the Accountable Care Organization (ACO) model stumble as the Health Maintenance Organization (HMO) model did in the 1990’s? ObamaCare provides for the existence of ACO’s, which are hospital-physician entities designed to provide comprehensive health care to patients in return for bundled payments. In this model the surgeon, the anesthesiologist, and the hospital (i.e. nurses, pharmacy, and the medical device industry) will divide up the bundled surgical payment. In this model it’s essential that an anesthesiologist leader has a strong presence at the negotiating table. A worrisome issue with the ACO model, as it was with the HMO model, is the flow of money. Physicians will no longer be working for their patients, but will be working for the ACO. The primary incentive will be to be paid by the ACO, rather than to provide the best care possible.
Anesthesia leadership skills will change. The physician leader of each anesthesia group must be a powerful and effective politician and economic strategist. These traits are not taught during anesthesia residency, and these traits have nothing to do with being an outstanding clinician.
What about the Perioperative Surgical Home (PSH)? The American Society of Anesthesiologists is proposing the model of the PSH, in which anesthesiologists will assume leadership roles managing patient care in the preoperative, intraoperative, and postoperative arenas. This is a desirable goal for our specialty. No physician is better equipped than an anesthesiologist to supervise patients safely through the perioperative period with the highest standards of quality and cost-control. The Perioperative Surgical Home is designed to work with the model of the Accountable Care Organization. How these systems of the Perioperative Surgical Home and the Accountable Care Organization will evolve remains to be seen. It will be the role for individual anesthesia physician leaders in each hospital to seize the new opportunities. Rank and file anesthesiologists will likely follow their leadership.

10. Consolidation of anesthesia groups. Small anesthesia groups will likely merge into bigger groups in an effort dominate a clinical census, and therefore to negotiate higher reimbursement rates. In November, 2013, the 100-physician Medical Anesthesia Consultants Medical Group, Inc, of San Ramon, California was acquired by Sheridan Healthcare Inc, a 2,500-physician services company based in Florida. Per Sheridan’s CEO, John Carlyle, the acquisition “provides a platform that will accelerate our expansion in the California marketplace.” This was the largest merger in Northern California anesthesia history.

11. Requirement of more anesthesia clinical metrics. Government and insurance payors will require more metrics to document that the provided clinical care was excellence. A typical required metric may be a high percentage of patients who received preoperative antibiotics prior to incision, or a low percentage of patients free from postoperative nausea and vomiting. Each anesthesia groups will need to establish computerized data-capturing systems to present this information to payors. The effort to tabulate these metrics will be another incentive for anesthesia groups to merge into larger clinical entities.

In summary: More patients, more cases, less money, more bureaucracy, less money, more CRNA providers, and less money. These are the challenges ObamaCare presents to anesthesiologists. Stay tuned. Legions of patients with ObamaCare cards will be knocking on hospital doors. The government is expecting enough anesthesiologists to sign up for ObamaCare contracts to make the new system successful. It’s impossible to tell what behaviors ObamaCare will incentivize. Each anesthesiologist has the benefit of 25+ years of education, and each anesthesiologist will make intelligent choices regarding their career and their time.

Bob Dylan once sang, “I ain’t gonna work on Maggie’s Farm no more.”

Time will tell if ObamaCare is Maggie’s Farm for physicians.

The most popular posts for laypeople on The Anesthesia Consultant include:

Why Did Take Me So Long To Wake From General Anesthesia?

The most popular posts for anesthesia professionals on The Anesthesia Consultant include:

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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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.

KIRKUS REVIEW

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:

WHY DOES ANYONE DECIDE THEY WANT TO BECOME AN ANESTHESIOLOGIST?

11 Sep 20136 May 2020THE ANESTHESIA CONSULTANT 17 Comments

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Recent Posts

How Long Will It Take To Wake Up From General Anesthesia?

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Latest posts by THE ANESTHESIA CONSULTANT (see all)

WRITING MEDICAL FICTION - 6 Dec 2023
HIGH FLOW NASAL OXYGEN:AN ANESTHESIA GAME-CHANGER - 15 Nov 2023
STANFORD EMERGENCY MANUAL POCKET VERSION - 28 Sep 2023

A question anesthesiologists are commonly asked is, “Why did you want to become an anesthesiologist?”

This image has an empty alt attribute; its file name is anesthesiologist.jpg

Let’s assume a young man or woman has the discipline and intellect to attend medical school. Once that individual gains their M.D. degree, they will choose a specialty from a long line-up that includes multiple surgical specialties (general surgery, orthopedics, urology, neurosurgery, cardiac surgery, ophthalmology, plastic surgery, ear-nose-and-throat surgery), internal medicine, pediatrics, family practice, dermatology, radiology, invasive radiology, radiation oncology, allergy-immunology, emergency medicine, and anesthesiology.

Why choose anesthesiology? I offer up a list of the reasons individuals like myself chose this specialty:

Anesthesiologists do acute care rather than clinic care or chronic care. Some doctors enjoy sitting in a clinic 40+ hours a week, talking to and listening to patients. Other doctors prefer acute care, where more exciting things happen moment to moment. It’s true that surgeons do acute care in the operating room, but most surgeons spend an equal amount of time in clinic, seeing patients before and after scheduled surgical procedures. Chronic care in clinics can be emotionally taxing. Ordering diagnostic studies and prescribing a variety of pills suits certain M.D.’s, but acute care in operating rooms and intensive care units is more stimulating. It’s exciting controlling a patient’s airway, breathing, and circulation. It’s exciting having a patient’s life in your hands. Time flies.
Patients like and respect their anesthesiologist, and that feels good. Maybe it’s because we are about to take each patient’s life into our hands, but during those minutes prior to surgery, patients treat anesthesiologists very well. I tend to learn more about my patients’ personal lives, hobbies, and social history in those 10 minutes of conversation prior to surgery than I ever did in my internal medicine clinic.
An anesthesiologist’s patients are unconscious the majority of time. Some anesthesiologists are attracted to this aspect. An unconscious patient is not complaining. In contrast, try to imagine a 50-hour-a-week clinic practice as an internal medicine doctor, in which every one of your patients has a list of medical problems they are eager to tell you about.
There is tremendous variety in anesthesia practice. We take care of patients ranging in ages from newborns to 100-year-olds. We anesthetize patients for heart surgery, brain surgery, abdominal or chest surgeries, bone and joint surgeries, cosmetic surgery, eye surgery, urological surgery, trauma surgery, and organ transplantation surgery. Every mother for Cesarean section has an anesthetist, as do mothers for many vaginal deliveries for childbirth. Anesthesiologists run intensive care units and anesthesiologists are medical directors of operating rooms as well as pain clinics.
Anesthesiologists work with a lot of cool gadgets and advanced technology. The modern anesthesia workstation is full of computers and computerized devices we use to monitor patients. The modern anesthesia workstation has parallels to a commercial aircraft cockpit.
Lifestyle. We work hard, but if an anesthesiologist chooses to take a month off, he or she can be easily replaced during the absence. It’s very hard for an office doctor to take extended time away from their patients. Many patients will find an alternate doctor during a one month absence if the original physician is unavailable. This aspect of anesthesia is particularly attractive to some female physicians who have dual roles as mother and physician, and choose to work less than full-time as an anesthesiologist so they can attend to their children and family.
Anesthesia is a procedural specialty. We work with our hands inserting IV’s, breathing tubes, central venous IV catheters, arterial catheters, spinal blocks, epidural blocks, and peripheral nerve blocks as needed. It’s fun to do these procedures. Historically, procedural specialties have been higher paid than non-procedural specialties.

What about problematic issues with a career in anesthesia? There are a few:

We work hard. Surgical schedules commonly begin at 7:30 a.m., and anesthesiologists have to arrive well before that time to prepare equipment, evaluate the first patient, and get that patient asleep before any surgery can commence. After years of this, my internal alarm clock tends to wake me at 6:00 a.m. even on weekends.
Crazy hours. Every emergency surgery—every automobile accident, gunshot wound, heart transplant, or urgent Cesarean section at 3 a.m. needs an anesthetist. Working around the clock can wear you out.
The stakes are high if you make a serious mistake. In a clinic setting, an M.D. may commit malpractice by failing to recognize that a patient’s vague chest pain is really a heart attack, or an M.D. may fail to order or to check on an important lab test, leading to a missed diagnosis. But in an operating room, the malpractice risks to an anesthesiologist are dire. A failure in properly insert a breathing tube can lead to brain death in minutes. This level of tension isn’t for everyone. Some doctors are not emotionally suited for anesthesia practice.
In the future, anesthesia doctors may gradually lose market share of their practice to nurse anesthetists. You can peruse other columns in this blog where I’ve discussed this issue.
Anesthesiologists don’t bring any patients to a medical center. In medical politics, this can be problematic. Anesthesiologists have limited power in some negotiations, because we can be seen as service providers rather than as a source of new patient referrals for a hospital. Some hospital administrators see an anesthetist as easily replaced by the next anesthetist who walks through the door, or who offers to work for a lower wage.

The positive aspects of anesthesiology far outweigh these negatives.

Akin to the Dos Equis commercial that describes “The Most Interesting Man in the World,” I’d describe the profession of anesthesiology as “The Most Interesting Job in the World.”

And when you love your job, you’ll never work a day in your life.

The most popular posts for laypeople on The Anesthesia Consultant include:

Why Did Take Me So Long To Wake From General Anesthesia?

The most popular posts for anesthesia professionals on The Anesthesia Consultant include:

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

CAN YOU CHOOSE YOUR ANESTHESIOLOGIST?

2 Apr 201316 Nov 2018THE ANESTHESIA CONSULTANT Leave a comment

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Recent Posts

How Long Will It Take To Wake Up From General Anesthesia?

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Latest posts by THE ANESTHESIA CONSULTANT (see all)

WRITING MEDICAL FICTION - 6 Dec 2023
HIGH FLOW NASAL OXYGEN:AN ANESTHESIA GAME-CHANGER - 15 Nov 2023
STANFORD EMERGENCY MANUAL POCKET VERSION - 28 Sep 2023

You choose the car you drive, the apartment you rent, the smart phone in your pocket, and the flavor of ice cream among 31 flavors at Baskin-Robbins. Most of you choose your family physician, your dermatologist, and your surgeon. But can you choose your anesthesiologist?

It depends.

To answer the question, let’s look at how anesthesia providers are assigned for each day of surgery.

Who makes the decision as to which anesthesia provider is assigned to your case? The anesthesia service at every hospital or healthcare system will have a scheduler. This scheduler is an individual (usually an anesthesiologist) who surveys the list of the surgical cases one day ahead of time. There will be multiple operating rooms and multiple cases in each operating room. Each operating room is usually scheduled for six to ten hours of surgical cases. The workload could vary from one ten-hour case to eight shorter cases. The total number of operating rooms will vary from hospital to hospital. Typically each room is specialty-specific, that is, all the cases in each room are the same type of surgery. The scheduler will an assign appropriate anesthesia provider to each room, depending on the skills of the anesthesia provider and the type of surgery in that room.

There are multiple surgical specialties and multiple types of anesthetics. An important priority is to schedule an anesthesia provider who is skilled and comfortable with the type of surgery scheduled. An open-heart surgery will require a cardiac anesthesiologist. A neonate (newborn) will require a pediatric anesthesiologist. Most surgeries, e.g., orthopedic, gynecologic, plastic surgery, ear-nose-and-throat, abdominal, urologic, obstetric, and pediatric cases over age one, are bread-and-butter anesthetics that can be handled by any well-trained provider.

Each day certain anesthesiologists are “on-call.” When an anesthesiologist is on-call, he or she is the person called for emergency add-on surgeries that day and night. The on-call anesthesiologist is expected to work the longest day of cases, and the scheduler will usually assign that M.D. to an operating room with a long list of cases. If you have emergency surgery at 2 a.m., you will likely be cared for by the on-call anesthesiologist. A busy anesthesia service may have a first-call, a second-call, and a third-call anesthesiologist, a rank order that defines which anesthesia provider will do emergency cases if two or three come in simultaneously. A busy anesthesia service will have on-call physicians in multiple specialties, i.e., there will be separate on-call anesthesiologists for cardiac cases, trauma cases, transplant cases, and obstetric cases.

Different hospitals have different models of anesthesia services. In parts of the United States, especially the Midwest, the South, and the Southeast, the anesthesia care team is a common model. An anesthesia care team consists of both certified registered nurse anesthetists (CRNA’s) and M.D. anesthesiologists. For complex cases such as cardiac cases or brain surgeries, an M.D. anesthesiologist may be assigned as the solitary anesthesia provider. For simple cases such as knee arthroscopies or breast biopsies, the primary anesthesia provider in each operating room will be a CRNA, with one M.D. anesthesiologist serving as the back-up consultant for up to four rooms managed by CRNA’s.

In certain states, the state governor has opted out of the requirement that an M.D. anesthesiologist must supervise all CRNA-provided anesthesia care. In these states, a CRNA may legally provide anesthesia care without a physician supervising them. Currently, the seventeen states that have opted out of physician supervision of CRNA’s include Alaska, California, Colorado, Iowa, Idaho, Kansas, Kentucky, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, South Dakota, Washington, and Wisconsin. In some hospitals in these states, your anesthesia provider may be an unsupervised nurse anesthetist, not a doctor at all.

Some hospitals have only M.D. anesthesiologists who personally do all the cases.

Academic hospitals, or university hospitals, have residents-in-training who administer most of the anesthetic care. In academic hospitals, faculty members supervise anesthesia residents in a ratio of one faculty to one resident or one faculty to two residents.

Can a surgeon request a specific anesthesia provider? Yes. At times, a surgeon may have certain anesthesia providers that he or she requests and uses on a regular basis. It’s far easier for a surgeon to request a specific anesthesia provider than it is for you to do so.

The assignment of your anesthesia provider is usually made by the scheduler on the afternoon prior to surgery, and you the patient will have little or no say in the matter. If you are like most patients, you have no idea who is an excellent anesthesia provider and who is less skilled. You won’t find much written about anesthesiologists on Yelp, Healthgrades, or other consumer social-media websites. Most patients don’t even remember the name of their anesthesia provider unless something went drastically wrong. Such is the nature of our specialty. Your anesthesia provider will spend a mere ten minutes with you while you’re awake, and during those ten minutes your mind will be reeling with worries about surgical outcomes and risks of anesthesia. The anesthesia provider’s name is not a high priority. After the surgery is over, anesthesiologists are a distant memory.

What if your next-door neighbor is an anesthesiologist whom you respect? What if you are scheduled for surgery at his hospital or surgery center, and you want him to take care of you? Can this be arranged? Most likely, it can. The best plan for requesting a specific anesthesiologist is to have the anesthesiologist work the system from the inside, several days prior to your surgery date. He will talk to the scheduler and make sure that he is assigned into the operating room list that includes your surgery. You’ll be happy and reassured to see him on the day of surgery, and he’ll likely be happy to take care of you. Anesthesiologists love to be requested by patients. It makes us feel special. Doctors aspire to be outstanding clinicians, and a request from a specific patient validates that we are unique.

As you can see, the decision of who is assigned to be the anesthesia provider for your surgery is a multifaceted process. Your best strategy for requesting a specific anesthesiologist is to (1) contact the anesthesiologist yourself and ask that he or she contact anesthesia scheduling and make sure that he or she is scheduled to do your case, or (2) contact your surgeon and ask your surgeon if they can arrange to have the specific anesthesia provider that you request.

The most popular posts for laypeople on The Anesthesia Consultant include:

Why Did Take Me So Long To Wake From General Anesthesia?

The most popular posts for anesthesia professionals on The Anesthesia Consultant include:

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

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:

ROBOT ANESTHESIA

27 Nov 20127 Feb 2022THE ANESTHESIA CONSULTANT 4 Comments

Author
Recent Posts

How Long Will It Take To Wake Up From General Anesthesia?

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Latest posts by THE ANESTHESIA CONSULTANT (see all)

WRITING MEDICAL FICTION - 6 Dec 2023
HIGH FLOW NASAL OXYGEN:AN ANESTHESIA GAME-CHANGER - 15 Nov 2023
STANFORD EMERGENCY MANUAL POCKET VERSION - 28 Sep 2023

Will robots replace anesthesiologists? I am the Medical Director of a surgery center in California that does 5,000 gastroenterology endoscopies per year. In 2013 a national marketing firm contacted me to seek my opinion regarding an automated device to infuse propofol. The device was envisioned as a tool for gastroenterologist/nursing teams to use to administer propofol safely for endoscopy procedures on ASA class I – II patients.

The marketing firm could not reveal the name of the device, but I believe it was probably the SEDASYS®-Computer-Assisted Personalized Sedation System, developed by the Ethicon Endo-Surgery, Inc., a division of Johnson and Johnson. The SEDASYS System is a computer-assisted personalized sedation system integrating propofol delivery with patient monitoring. The system incorporates standard ASA monitors, including end-tidal CO2, into an automated propofol infusion device.

The SEDASYS system is marketed as a device to provide conscious sedation. It will not provide deep sedation or general anesthesia.

Based on pharmacokinetic algorithms, the SEDASYS infuses an initial dose of propofol (typically 30- 50 mg in young patients, or a smaller dose in older patients) over 3 minutes, and then begins a maintenance infusion of propofol at a pre-programmed rate (usually 50 mcg/kg/min). If the monitors detect signs of over- sedation, e.g. falling oxygen saturation, depressed respiratory rate, or a failure of the end-tidal CO2 curve, the propofol infusion is stopped automatically. In addition, the machine talks to the patient, and at intervals asks the patient to squeeze a hand-held gripper device. If the patient is non-responsive and does not squeeze, the propofol infusion is automatically stopped.

As of February, 2013, the SEDASYS system was not FDA approved. On May 3, 2013, Ethicon Endo-Surgery, Inc. announced that the Food and Drug Administration (FDA) granted Premarket Approval for the SEDASYS® system, a computer-assisted personalized sedation system. SEDASYS® is indicated “for the intravenous administration of 1 percent (10 milligrams/milliliters) propofol injectable emulsion for the initiation and maintenance of minimal to moderate sedation, as identified by the American Society of Anesthesiologists Continuum of Depth of Sedation, in adult patients (American Society of Anesthesiologists physical status I or II) undergoing colonoscopy and esophagoduodenoscopy procedures.” News reports indicate that SEDASYS® is expected to be introduced on a limited basis beginning in 2014.

Steve Shaffer, M.D., Ph.D., Stanford Adjunct Professor, editor-in-chief of Anesthesia & Analgesia, and Professor of Anesthesiology at Columbia University, worked with Ethicon since 2003 on the design, development and testing of the SEDASYS System both as an investigator and as chair of the company’s anesthesia advisory panel.

Dr. Shafer has been quoted as saying, “The SEDASYS provides an opportunity for anesthesiologists to set up ultra-high throughput gastrointestinal endoscopy services, improve patient safety, patient satisfaction, endoscopist satisfaction and reduce the cost per procedure.” (Gastroenterology and Endoscopy News, November 2010, 61:11)

In Ethicon’s pivotal study supporting SEDASYS, 1,000 ASA class I to III adults had routine colonoscopy or esophagogastroduodenoscopy, and were randomized to either sedation with the SEDASYS System (SED) or sedation with each site’s current standard of care (CSC) i.e. benzodiazepine/opioid combination. The reference for this study is Gastrointest Endosc. 2011 Apr;73(4):765-72. Computer-assisted personalized sedation for upper endoscopy and colonoscopy: a comparative, multicenter randomized study. Pambianco DJ, Vargo JJ, Pruitt RE, Hardi R, Martin JF.

In this study, 496 patients were randomized to SED and 504 were randomized to CSC. The area under the curve of oxygen desaturation was significantly lower for SED (23.6 s·%) than for CSC (88.0 s·%; P = .028), providing evidence that SEDASYS provided less over-sedation than current standard of care with benzodiazepine/opioid. SEDASYS patients were significantly more satisfied than CSC patients (P = .007). Clinician satisfaction was greater with SED than with CSC (P < .001). SED patients recovered faster than CSC patients (P < .001). The incidence of adverse events was 5.8% in the SED group and 8.7% in the CSC group.

Donald E. Martin, MD, associate dean for administration at Pennsylvania State Hershey College of Medicine and chair of the Section on Clinical Care at the American Society of Anesthesiologists (ASA), expressed concerns about the safety of the device. Dr. Martin (Gastroenterology and Endoscopy News, November 2010, 61:11) was quoted as saying, “SEDASYS is requested to provide minimal to moderate sedation and yet the device is designed to administer propofol in doses known to produce general anesthesia.”

Dr. Martin added that studies to date have shown that some patients who had propofol administered by SEDASYS experienced unconsciousness or respiratory depression (Digestion 2010;82:127-129, Maurer WG, Philip BK.). In the largest prospective, randomized trial evaluating the safety of the device compared with the current standard of care, five patients (1%) experienced general anesthesia with SEDASYS. The ASA also voiced concern that SEDASYS could be used in conditions that do not comply with the black box warning in the propofol label, namely that propofol “should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure.”

Anesthetists, emergency room doctors, and trauma helicopter nurses are trained in the administration of general anesthesia. Gastroenterologists and endoscopy nurses are almost never experts in airway management. For this reason, propofol anesthetics for endoscopy are currently the domain of anesthesiologists and nurse anesthetists.

In my phone conversation regarding the automated propofol-infusion system, I told the marketing company’s representative that in my opinion a machine that infused propofol without an airway expert present could be unsafe. The marketing consultant responded that in parts of the Northeastern United States, including New York City, many GI endoscopies are done with the assistance of an anesthesia provider administering propofol. If SEDASYS were to be approved, the devices could replace anesthesiologists.

In the current fee-for-service model of anesthesia billing, anesthesiologists and CRNA’s bill insurance companies or Medicare for their professional time. If machines replace anesthesiologists and CRNA’s, the anesthesia team cannot send a fee-for-service bill for professional time. The marketing consultant foresaw that with the advent of ObamaCare and Accountable Care Organizations, if a health care organization is paid a global fee to take care of a population rather than being paid a fee-for-service sum, then perhaps the cheapest way to administer propofol sedation for GI endoscopy would be to replace anesthesia providers with SEDASYS machines.

A planned strategy is to have gastroenterologists complete an educational course that would educate them on several issues. Key elements of the course would be: 1) anesthesiologists are required if deep sedation is required, 2) SEDASYS is not appropriate if the patient is ASA 3 or 4 or has severe medical problems, 3) SEDASYS is not appropriate if the patient has risk factors such as morbid obesity, difficult airway, or sleep apnea, and 4) airway skills are to be taught in the simulation portion of the training. Specific skills are chin life, jaw thrust, oral airway use, nasal airway use, and bag-mask ventilation. Endotracheal intubation and LMA insertion are not to be part of the class. If the endoscopist cannot complete the procedure with moderate sedation, the procedure is to be cancelled and rescheduled with an anesthesia provider giving deep IV sedation.

Some anesthesiologists are concerned about being pushed out of their jobs by nurse anesthetists. It may be that some anesthesiologists will be pushed out of their jobs by machines.

I’ve been told that the marketing plan for SEDASYS is for the manufacturer to give the machine to a busy medical facility, and to only charge for the disposable items needed for each case. The disposable items would cost $50 per case. In our surgery center, where we do 5,000 cases per year, this would be an added cost of $25,000 per year. There would be no significant savings, because we do not use anesthesiologists for most gastroenterology sedation.

There have been other forays into robotic anesthesia, including:

1) The Kepler Intubation System (KIS) intubating robot, designed to utilized video laryngoscopy and a robotic arm to place an endotracheal tube (Curr Opin Anaesthesiol. 2012 Oct 25. Robotic anesthesia: not the realm of science fiction any more. Hemmerling TM, Terrasini N. Departments of Anesthesia, McGill University),

2) The McSleepy intravenous sedation machine, designed to administer propofol, narcotic, and muscle relaxant to patients to control hypnosis, analgesia, and muscle relaxation. (Curr Opin Anaesthesiol. 2012 Dec;25(6):736-42. Robotic anesthesia: not the realm of science fiction any more. Hemmerling TM, Terrasini N.)

3) The use of the DaVinci surgical robot to perform regional anesthetic blockade. (Anesth Analg. 2010 Sep;111(3):813-6. Epub 2010 Jun 25. Technical communication: robot-assisted regional anesthesia: a simulated demonstration. Tighe PJ, Badiyan SJ, Luria I, Boezaart AP, Parekattil S.).

4) The use of the Magellan robot to place peripheral nerve blocks (Anesthesiology News, 2012, 38:8)

Each of these applications may someday lead to the performance of anesthesia by an anesthesiologist at geographical distance from the patient. In an era where 17% of the Gross National Product of the United States is already being spent on health care, one can question the logic of building expensive technology to perform routine tasks like I.V. sedation, endotracheal intubation, or regional block placement. The new inventions are futuristic and interesting, but a DaVinci surgical robot costs $1.8 million, and who knows what any of these anesthesia robots would sell for? The devices seem more inflationary than helpful at this point.

Will robots replace anesthesiologists? Inventors are edging in that direction. I would watch the peer-reviewed anesthesia journals for data that validates the utility and safety of any of these futuristic advances.

It will be a long time before anyone invents a machine or a robot that can perform mask ventilation. SEDASYS is designed for conscious sedation, not deep sedation or general anesthesia. Anyone or anything that administers general anesthesia without expertise in mask ventilation and all facets of airway management is courting disaster.

NOTE: In March of 2016, Johnson & Johnson announced that they were going to stop selling the SEDASYS system due to slow sales and company-wide cost cutting. The concept of Robot Anesthesia will have to wait for some future development, if ever, if it is to ever become an important part of the marketplace.

The most popular posts for laypeople on The Anesthesia Consultant include:

Why Did Take Me So Long To Wake From General Anesthesia?

The most popular posts for anesthesia professionals on The Anesthesia Consultant include:

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

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:

ANESTHESIOLOGISTS KNOW WHO THE BEST SURGEONS ARE

8 Aug 201219 Nov 2018THE ANESTHESIA CONSULTANT 2 Comments

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How Long Will It Take To Wake Up From General Anesthesia?

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Latest posts by THE ANESTHESIA CONSULTANT (see all)

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You’re a patient. Is your surgeon a wonderful doctor, superb under pressure, or is he or she a self-absorbed nervous individual who can’t operate their way out of a paper bag? You don’t know. Your anesthesiologist does. Anesthesiologists watch surgeons for a living.

Yes, we happen to give anesthetics to patients at the same time, but we anesthesiologists are always watching surgeons work. If you want to know who the best surgeons are, ask an anesthesiologist, an operating room nurse, or an operating room scrub tech. We see the surgeons on the front line, and we see their strengths and weaknesses.

Most surgeons spend the majority of their professional time in clinics, meeting patients in preoperative surgical consultations or in postoperative surgical follow up. Most surgeons operate 1 – 2 days per week. In contrast, most anesthesiologists have no clinic, and work 90-100% of their time in operating rooms. In a typical week, an anesthesiologist may do 20-25 anesthetics with 10 – 15 different surgeons. In a typical year, a busy anesthesiologist may work with 100 – 150 different surgeons.

In an operating room, the anesthesiologist stands 2 to 6 feet away from the surgeon, and has a clear view of the surgeon’s technique and an excellent opportunity to establish rapport with the surgical team. Anesthesiologists and surgeons know each other very well.

As a patient, you may form your impressions of your surgeon based on encounters in the office or in your hospital room. Favorable surgeons cast an air of confidence, intelligence, leadership and experience. You may trust the look in their eye, the tenor of their voice, the firmness of their handshake. You may like or dislike their necktie, their suit, their haircut or their bedside manner.

You have no idea how competent they are once they don sterile gown and gloves in the operating room, but anesthesiologists know.

The surgeon with the firm handshake may have hands that genuinely shake when they are in surgery. The slick-appearing surgeon may operate in low gear, their fingers moving as slowly as a twig winding downstream in a muddy river. In the operating room, the surgeon may be a benevolent professional or a moody tyrant who screams and swears at nurses and techs. The surgeon with the killer smile may cling to outdated techniques or equipment. Alternately, the surgeon may be world-class technician who knows his or her anatomy cold, handles tissue with exacting precision, and treats everyone on the surgical team like gold.

What can you, the patient, do about accessing information about your surgeon?

You can Google the surgeon’s name to seek information on their professional background, as well as any Yelp comments on other patient’s experiences with that doctor. If you know anyone who works at that hospital or surgery center, it’s worth your while to query them and get their insider’s impression about the choice of surgeons that work there. If you can talk to an anesthesiologist, operating room nurse, or operating scrub tech, they will be your best source of information as to which surgeon to consult.

Good luck. All surgeons are different. And remember: tonight when you are watching television, thousands of anesthesiologists are watching thousands of surgeons all over the United States.

The most popular posts for laypeople on The Anesthesia Consultant include:

Why Did Take Me So Long To Wake From General Anesthesia?

The most popular posts for anesthesia professionals on The Anesthesia Consultant include:

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

*
*
*
*

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

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:

IS ANESTHESIA 99% BOREDOM AND 1% PANIC?

15 Jul 20122 Sep 2020THE ANESTHESIA CONSULTANT 8 Comments

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How Long Will It Take To Wake Up From General Anesthesia?

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Latest posts by THE ANESTHESIA CONSULTANT (see all)

WRITING MEDICAL FICTION - 6 Dec 2023
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When you have surgery, do you care who administers your anesthetic? You should. An oft-repeated medical adage states:“anesthesia is 99% boredom and 1% panic.

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GOALIES AT THE PEARLY GATES

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, this book will teach you what to expect in anesthesia care, and what you can do to receive the best in anesthesia care.

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 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 would 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.

The most popular posts for laypeople on The Anesthesia Consultant include:

Why Did Take Me So Long To Wake From General Anesthesia?

The most popular posts for anesthesia professionals on The Anesthesia Consultant include:

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:

PEDIATRIC ANESTHESIA: WHO IS ANESTHETIZING YOUR CHILD?

3 May 201219 Nov 2018THE ANESTHESIA CONSULTANT 5 Comments

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How Long Will It Take To Wake Up From General Anesthesia?

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Latest posts by THE ANESTHESIA CONSULTANT (see all)

WRITING MEDICAL FICTION - 6 Dec 2023
HIGH FLOW NASAL OXYGEN:AN ANESTHESIA GAME-CHANGER - 15 Nov 2023
STANFORD EMERGENCY MANUAL POCKET VERSION - 28 Sep 2023

Your 4-year-old son Jake is scheduled for a tonsillectomy 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.

The most popular posts for laypeople on The Anesthesia Consultant include:

Why Did Take Me So Long To Wake From General Anesthesia?

The most popular posts for anesthesia professionals on The Anesthesia Consultant include:

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

*
*
*
*

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

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:

THE FUTURE: NURSE ANESTHETISTS OR M.D. ANESTHESIOLOGISTS?

4 Mar 20102 Oct 2018THE ANESTHESIA CONSULTANT Leave a comment

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Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Latest posts by THE ANESTHESIA CONSULTANT (see all)

WRITING MEDICAL FICTION - 6 Dec 2023
HIGH FLOW NASAL OXYGEN:AN ANESTHESIA GAME-CHANGER - 15 Nov 2023
STANFORD EMERGENCY MANUAL POCKET VERSION - 28 Sep 2023

Clinical Case for Discussion: You are appointed Chairman of Anesthesia at an acute-care California community hospital. The hospital administrator offers you a stipend to support the anesthesia care for his medical center, but it will be up to you to determine how to staff your operating rooms in the most cost-effective, safe, and efficient manner. What do you do?

Discussion: What will the future of anesthesia manpower and staffing in California look like? Will you be supervising an infantry of nurse anesthetists? Will you become the employee of another anesthesiologist who is your Medical Director? Let’s stroke the crystal ball:

In the Rovenstine lecture published in the May 2006 issue of Anesthesiology, Mark Warner, M.D. (ASA President-elect for 2010) wrote, “Do we really need our best and brightest physicians to sedate and monitor patients undergoing cataract procedures when these patients have only an infinitesimal risk of developing a life-threatening problem intraoperatively? Do we need them to deliver one-on-one care to healthy 20-year-olds who need general anesthetics for simple surgical procedures such as herniorrhaphies and peripheral orthopedic procedures? . . . There will be too few anesthesiologists, as well as insufficient funds to pay for such physician-intensive care. Further, there are no studies to suggest the need for physicians to personally deliver care to healthy patients undergoing minimally invasive procedures. As proven in a number of diverse practice models and in our intensive care units daily, physician oversight or supervision of well-trained sedation and critical care nurses, nurse anesthetists, and anesthesiologist assistants is a remarkably safe, efficient, and cost effective model for delivering care to appropriately selected patients. . . . We have truly outstanding anesthesiologists who provide terrific care in intensive care units across this country. None of them—not a single one of them—are assigned to provide one-on-one care to even the most critically ill patients in these units.”

On Friday March 20, 2009, the California Society of Anesthesiologists sponsored the first-ever meeting of the California anesthesia residency program directors, where representatives from all 11 anesthesia training programs in the state (UCSF, Stanford, UCLA, UCSD, San Diego Naval Hospital, UC Irvine, Harbor, Cedars-Sinai, USC, Loma Linda, and UC Davis) met at UCLA. A portion of the meeting focused on likely changes in anesthetic practice over the next three decades, and how to best train the newest generation of anesthesiology residents to prepare for that future.

Michael Champeau, at that time the President of the California Society of Anesthesiologists and Adjunct Professor of Anesthesia at Stanford, attended the UCLA meeting. According to Dr. Champeau, “the meeting attendees overwhelmingly felt that in order to remain economically viable in the changing health care world, anesthesiologists needed to expand the scope of services they provide beyond traditional one-on-one physician administered OR anesthesia to encompass the entire scope of perioperative medicine.”

Per Dr. Champeau, the program directors believed that the future of anesthesia will include a tiered spectrum of models of anesthesia care staffing ranging from a one-anesthesiologist-per-one-patient model for complex surgeries or complex patients down to one anesthesiologist supervising multiple nurse anesthetists (or Anesthesiologist’s Assistants, should they become licensed in California) for straightforward surgeries on healthy patients. He emphasized that the CSA was certainly not promoting the expansion of the anesthesia care team model, but rather simply bringing the leaders of the anesthesia residency training programs in California together, listening to their thoughts about the future of the specialty, and drawing attention to the likely economic consequences of the anticipated changes in modes of practice. The program directors believed that expertise in preoperative evaluation and optimization, risk stratification, operating room and perioperative team leadership, postoperative pain management and intensive care would be skills required for the anesthesiologist of the future.

While one-anesthesiologist-per-case staffing is currently the predominant model in California, Dr. Champeau went on to say that many groups might be only one entrepreneurial physician and one forward-thinking administrator away from changing to a tiered care model utilizing anesthesia care teams. Per data presented at the 2009 American Society of Anesthesia Conference on Practice Management, between 60-70% of anesthesia groups in the country are supported by a hospital stipend subsidy. If utilizing the anesthesia care team model costs less than an all-physician model for anesthesia care, there may be increasing pressure in the upcoming years for utilizing anesthesia care teams.

In the U.S., solo M.D. practitioners deliver 35% of the anesthetics, anesthesia care teams with anesthesiologists medically directing Anesthesiologist Assistants or CRNAs deliver 55% of the anesthetics, and CRNAs in solo practice deliver 10% of the anesthetics. The anesthesia care team model is less common in California, partly because the supply of anesthesiologists in California is sufficient to staff most cases without CRNAs.

The Kaiser system in California utilizes the anesthesia care team model. David Newswanger, M.D., the Chairman of Anesthesia at Kaiser Santa Clara, told me the following key facts about his department: His anesthesia staff includes 21 anesthesiologists in the general O.R., 7 anesthesiologists in the cardiac O.R., and 29 CRNA’s. This staff covers 19 O.R.’s in three locations. In the Ambulatory Surgery Center and in the Eye Center, 90% of the cases are done by CRNA’s supervised in a 4:1 or 3:1 CRNA:anesthesiologist ratio. In the main O.R., anesthesiologists working alone cover 50% of the cases (more complex cases such as abdominal aortic aneurysms or thoracic cases), and supervised CRNA’s cover the other 50% of cases. Kaiser has a system for assessing which patients are appropriate for an anesthesia care team and which need a solo anesthesiologist. A Preoperative Clinic team of 7 Nurse Practitioners screens 35% of pre-surgery patients, an MD anesthesiologist examines 5%, and medical assistants interview the remaining 60% by telephone and fill out standardized, preoperative questionnaires.

Back to our clinical case from the beginning of the column: (1) Would you hire both MDs and CRNAs, utilizing the anesthesia care team model? (2) Would you hire anesthesiologist employees and pay them the lowest salary you possibly could? (3) Would you assemble a team of anesthesiologists as equal partners?

Regarding the Kaiser CRNA anesthesia care team model, for a small hospital the start-up costs for staffing a pre-operative clinic and hiring enough anesthesiologists to cover all the night call may not leave any cost savings. According to Dr. Newswanger, in the capitated Kaiser model a CRNA is equivalent to 2/3 of an anesthesiologist when it comes to the economics of O.R. staffing. That is, if he staffs his O.R.’s at a 3:1 ratio of CRNA:anesthesiologist, it’s a break-even point (1 + 3 X 2/3 = 3 M.D. equivalents for 3 O.R.s), whereas a 4:1 ratio is a money-saving staffing scenario (1 + 4 X 2/3 = 3 2/3 M.D. equivalents for 4 O.R.s). In a fee-for-service practice, these numbers may be different, depending on the payer-mix of the patients.

Regarding the second option, a Medical Director anesthesiologist employing a team of lower-paid anesthesiologist employees, a central issue is that most anesthesiologists shun lower paying positions, and these hospital departments may be doomed to understaffing and high turnover. The third option, assembling a team of equal-partner anesthesiologists, avoids these problems but may be less cost-effective.

There are specific concerns in staffing out-of-hospital surgery centers and office-based anesthetic locations. I currently work in a one-anesthesiologist-per-patient private practice in which 15% of our cases are done in locations where there is only one operating room in a surgery center or a plastic surgery center. In these settings, there is be no cost saving to having both an M.D. and a CRNA present to do the anesthetic, and a solo anesthesiologist-per-patient seems the likely staffing model. The question regarding the safety of replacing that solo anesthesiologist with a solo CRNA is a heated and separate issue that will not be discussed in this column.

The crystal ball is murky, and no one knows if the anesthesia care team model will turn out to be a dominant form of practice in California. While the specifics of future anesthesia care staffing in California are uncertain, I am optimistic that the future will involve vigilant, high quality perioperative medicine, led by physician anesthesiologists.

Learn more about Rick Novak’s fiction writing at rick novak.com by clicking on the picture below:

WHAT IF YOUR SON NEEDS AN EMERGENCY APPENDECTOMY ON VACATION?

2 Mar 20102 Oct 2017THE ANESTHESIA CONSULTANT 1 Comment

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