MERITS OF PHYSICIAN ANESTHESIOLOGY

the anesthesia consultant

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

Some people have difficulty seeing the outstanding merits of physician anesthesiology. I understand where these opinions come from, but the phenomenon still bothers me.

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Today I read a thoughtful and well-written essay in Anesthesiology News titled, Anesthesiologists-The Utility Players of the Medical Field written by anesthesiologist David Stinson MD from my native state of Minnesota. His thesis is that, like utility players on a baseball team, we are valuable but suffer an identity crisis. He writes, “Our specialty, anesthesia, has suffered an identity crisis for decades. Are we the ‘captain of the ship’ or is the surgeon? . . . It is never quite clear and the answer changes with location and context. Are we physicians or are we glorified advanced practice nurses?”

To me, the appropriate headline should read, “Anesthesiologists—the Most Valuable Players of the Medical Team.” I’d like to see an anesthesiologist saying, “I’m going to Disney World” at the end of the Super Bowl before picking up his (or her) MVP trophy.

Why would I say this? Two anecdotes will illustrate why I understand the problem. In the late 1970’s I was a third-year medical student at a prominent Midwestern medical school, where an unspoken rank system existed in the operating room. The surgical attendings were the kings, the students were the peasants, the nurses and techs were serfs, and the anesthesiologists were the whipping boys for the surgeons. I witnessed consistent verbal abuse, bullying, condescending barking commands, and lack of respect directed from surgeons toward anesthesiologists. One day I was scrubbed in as a retractor-holding medical student on a 12-hour esophagectomy, and at the conclusion of the procedure the attending surgeon removed his gloves and gown and left the room to talk to the family. Five minutes later, the patient had a cardiac arrest. The resuscitation was not successful, and the patient died. Afterward the surgeon bellowed his disapproval regarding how the anesthesia team had failed to keep the patient alive after he had spent all day “curing” the patient. It was an unforgettable experience to me, and one of the take-home messages was that I never wanted to be an anesthesiologist.

Fast-forward three years into the future, when I was an internal medicine resident at Stanford serving my medical intensive care unit rotation. The anesthesiology department ran the ICUs at Stanford during the 1980’s. The ICU attendings were charismatic, smart, decisive, impressive role models. The ICU attendings had respectful peer relationships with all the surgeons, including the private-practice cardiac surgeons whose post-operative patients were housed in the ICU. Morning rounds, evening rounds, and the eight hours in between were filled with action, procedures, upbeat emotions, and encouraging talk about the specialties of anesthesiology and critical care medicine. The Stanford anesthesia residents boasted of weekdays off after their nights on call, Learjet trips to harvest donor hearts for Dr. Norm Shumway’s cardiac transplant patients, weeklong trips to third-world countries to perform anesthetics on cleft lip and palate patients, and best of all, the excitement of inserting endotracheal tubes, arterial lines, central lines, Swan Ganz catheters, spinal and epidural needles into patients of all sizes and surgical needs. This was alluring to internal medicine residents. Each year a significant number of internal medicine residents applied for admittance to anesthesiology residencies, which is what I did. Were surgeons hollering at the anesthesiologists at Stanford? In a word . . . no. The department had the respect of the surgeons. This was the environment I grew up in, and the professional spirit we all should aspire to.

Here are 10 reasons why anesthesiologists should hold their heads high and never have a molecule of low self esteem around their medical center:

  1. All of acute care medicine is based on A-B-C, or Airway-Breathing-Circulation. Operating room medicine, intensive care medicine, emergency room medicine, trauma helicopter medicine, and battlefield medicine are all based on A-B-C, or Airway-Breathing-Circulation. Who are the experts of the A, or Airway? Anesthesiologists are the experts. There can be no acute care resuscitation without someone managing the airway, usually with an endotracheal tube. It’s true that other medical professionals have abilities to place endotracheal tubes, but none of them have the breadth of skills, techniques, and volume of attempts as anesthesiologists do. Hold your heads high. Read my column on bullying in the operating room. Don’t put up with condescending behavior from a surgeon. Surgeons know how to wield a scalpel. You know how to wield the most valuable tool of all medical equipment, the laryngoscope.78432-7985650
  2. It’s true that surgeons bring the patients to the operating room for surgery. It’s just as true that none of those patients would agree to the operations without having an anesthetic. The anesthesiologist’s role is vital.
  3. Clinic doctors are important. They manage primary care as well as outpatient specialty care. They make diagnoses and prescribe therapeutic medicines. Anesthesiologists also partake in clinic care in preoperative clinics and pain clinics. An anesthesiologist’s knowledge of internal medicine isn’t as comprehensive as a board-certified internist, but the consider the flip side: None of the internists can administer general anesthesia, regional anesthesia, or manage the A of the A-B-Cs like an anesthesiologist can. I was an internal medicine doctor who lacked these skills and then acquired them during anesthesia residency. Trust me—internists envy the skills of anesthesiologists.
  4. Anesthesiologists deal with life and death situations on a regular basis. Clinic doctors, including surgeons on their days in clinic, listen to and talk to patients. There is no peril in outpatient clinic medicine. On any given day at your job as an anesthesiologist you could be attending to a morbidly obese adult, a tiny child, a frail geriatric patient, or an emergency thoracic case. Your heart rate will climb as high as the patient’s, and you’ll manage the circumstances. Anesthesiologists are goalies at the Pearly Gates, and we should be proud of it.
  5. Physician anesthesiologists have a fascinating job. Anesthesiologists administer anesthetics to virtually every specialty: general surgery, cardiac surgery, neurosurgery, obstetrics, gynecology, otolaryngology, orthopedic surgery, podiatry, ophthalmology, plastic surgery, psychiatry for electroshock therapy, invasive radiologists, cardiologists, oral surgeons, dentists, and pediatric surgeons. The breadth of knowledge across specialties is unrivaled by any other physician.
  6. Who is the captain of the ship in the operating room? Is it the surgeon or is it the anesthesiologist? My advice is: don’t concede the role to your surgical colleague alone. He or she knows how to do the operation. You know how to do the anesthetic. It is a symbiotic relationship. Do not lay yourself down on the ground in reverence. In the words of the Eagles song “Peaceful Easy Feeling,” “she can’t take you anywhere you don’t already know how to go.” If you see and feel yourself as the servant, second in command, that’s where you’ll find yourself . . . as the servant, second in command. Step up. Be an equal. Be in control of your domain, a critical domain.
  7. Physician anesthesiologists are well paid. Per U. S. News and World Report, an anesthesiologist is the highest paying job in America. Think about that. There are 325 million people in our country, and there are thousands of different job descriptions. Your profession is the highest paid. Be proud of that.
  8. Physician anesthesiologists are in demand. As I write this in 2018, I receive multiple emails per day seeking attending anesthesiologists for jobs around the USA. If you’re willing to relocate and be mobile, you’ll find numerous suitors competing for your services as an attending anesthesiologist. Per U.S. News and World Report, the unemployment rate for anesthesiologists is a paltry 0.5%.
  9. Physician anesthesiologists help people every day. You could be selling Coca Cola or cell phones or cell phone data networks or stocks. Would you be serving humanity as well if you were working in some business job? You have the opportunity to change lives for hundreds of patients per year.
  10. Maybe you’re worried that nurse anesthetists will take your job away. I have no crystal ball to foretell the future, but consider these things: (a) Most CRNAs work in anesthesia care team models with our physician anesthesiologist colleagues, and this MD-CRNA relationship is a well accepted model of patient care that will persist into the future; (b) Physician anesthesiologists are needed for leadership roles in clinical care, administration, committees, and quality assurance; and (c) Remember that you are a physician and CRNAs are not. Keep up your skills. The large medical systems of the future will tier their anesthesia coverage. Complex cases will always require MD anesthesiologists. It’s likely that simple cases such as cataracts, lymph node biopsies, and knee arthroscopies can be safely done with CRNA anesthesia. Continue to seek out and perform difficult anesthetic cases only an MD would feel comfortable doing. If you find yourself attending to only ASA I an ASA II patients for straightforward surgeries, you may indeed find your job taken by someone with less training. Instead, step up. Be proud of your training, your unique skills, the heritage of your profession, and the esteem of your standing among your fellow physicians.

 

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WHEN SURGEONS, OR PATIENTS, TRY TO TELL THE ANESTHESIOLOGIST WHAT TO DO — 14 EXAMPLES

the anesthesia consultant

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

You’re a board-certified anesthesiologist. You’ve graduated from a residency program in which you learned the nuances of preoperative, intraoperative, and postoperative anesthesia practice. Yet at times, surgeons or patients will ask you to do something counter to your medical judgment.

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Individuals would never board a Boeing 787 aircraft and tell the pilot what to do, but individuals will try to influence their anesthesiologist.

Let’s look at some examples:

 

WHEN SURGEONS TRY TO TELL THE ANESTHESIOLOGIST WHAT TO DO:

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  1. “This patient’s not too sick. You’re wrong to cancel his surgery.” In an example of this scenario, an orthopedic surgeon tries to convince you that the 65-year-old obstructive sleep apnea patient with a BMI of 40 who never walks further than the distance from his couch to his kitchen table is “not that sick,” and that you should not cancel the patient’s rotator cuff repair at a freestanding outpatient surgery center. Trust your training and your intuition. You believe the patient is high risk in terms of his airway, his breathing, his cardiac status, and his potential for post-operative complications. You’re trained in perioperative medicine. The orthopedic surgeon is trained in the management of joint and bone disorders. Tell the surgeon that the patient needs to have cardiac clearance prior to any general anesthetic, and that the case needs to be done in a hospital setting rather than at a freestanding surgery center.
  2. “Just do MAC (Monitored Anesthesia Care) anesthesia for this case, but make sure he’s asleep. My patient doesn’t want to hear anything.” In an example of this scenario, a surgeon schedules an inguinal hernia repair as a MAC anesthetic. The surgeon intends to supplement your intravenous (IV) sedation with local anesthetic at the surgical site. The surgeon told the patient to expect “a twilight sleep during the surgery.” You discuss this with the surgeon, who requests you, “Just give the patient sedation with propofol.” Per the American Society of Anesthesiologists Continuum of Depth of Sedation, if a patient is unarousable even with painful stimulation, that is a general anesthetic. In contrast, if a patient shows purposeful response following repeated or painful stimulation, that is deep sedation. It’s possible to infuse propofol and keep a patient purposefully responsive, but very few of us do this. Propofol infusions are typically used to make our patients sleep, and most propofol infusions cross the American Society of Anesthesiologists line into general anesthesia. If there is a complication or a bad outcome after the surgery, and you delivered general anesthesia when the operating room schedule said MAC and your preoperative anesthesia note stated the anesthesia plan was MAC, then you’re at medical-legal risk for delivering a deeper anesthetic than what was documented on the schedule and on your anesthetic plan.
  3. “Can you do an axillary block for this finger surgery?” In an example of this scenario, the surgeon requests an axillary block for a debridement of a finger surgery. You’re comfortable placing ultrasound-assisted regional anesthetic blocks, but you’re not confident with this particular block. You discuss other options with the surgeon, and suggest he places a digital block, which is more specific and incurs less risks than the axillary block. He pushes back, wanting you to do the axillary block. But if you don’t want to do the block, you don’t have to. You’re in charge of the anesthetic. You make the decision. The case proceeds with intravenous sedation, the surgeon complies with your request and blocks the base of the finger with local anesthesia, and the patient does fine.
  4. “This patient doesn’t need an arterial line (or a central venous pressure line).” In an example of this scenario, an 70-year-old woman with aortic stenosis is about to undergo an exploratory laparotomy for a perforated bowel. You’re concerned about maintaining her cardiac output, blood pressure, and blood volume during the surgery, and decide she needs an arterial line prior to induction and an internal jugular CVP after induction. The surgeon, in a hurry to proceed with the laparotomy, tells you neither of these lines is necessary. Your answer? Because you’re the expert in perioperative medicine, you tell him you need those lines and you will put them in. If there is a death or a dire cardiovascular complication, you’ll be the physician who will face the criticism if you did not place the lines. Blaming the surgeon will not protect you.
  5. After the conclusion of a surgery, the surgeon says, “What are you waiting for? Extubate the patient. She is bucking and coughing. Extubate the patient!” In an example of this scenario, after the conclusion of a tonsillectomy, you turn off the anesthetics. The patient eventually coughs and bucks on the endotracheal tube, but has not opened her eyes. When you open her eyelids, you note that her gaze is dysconjugate. You’re concerned that if you extubate the trachea, this still-emerging patient could develop laryngospasm. The surgeon then says, “When are you going to extubate? All this coughing is raising the blood pressure, and will cause bleeding and I’ll have a complication.” What should you do? Anesthesia practice must always follow the priorities of A-B-C, or Airway-Breathing-Circulation. You’re in charge of the airway. The endotracheal tube is your friend until the patient opens her eyes, is awake and responsive, and can maintain her own airway. Take out the breathing tube when you’re ready, not when the surgeon asks you to.
  6. Near the conclusion of surgery the surgeon says, “I’d like you to please extubate this patient deep.” In an example of this scenario, a patient has just received a five-hour general anesthetic for a facelift. As in the example above, the surgeon is concerned that coughing or bucking on the endotracheal tube at emergence will elevate the blood pressure and cause increased postsurgical bleeding. What should you do? Again, follow your training and experience. Anesthesia practice must always follow the priorities of A-B-C, or Airway-Breathing-Circulation. You’re in charge of the airway. The endotracheal tube is your friend until your patient opens her eyes, is awake and responsive, and can maintain her own airway. Certain slender, healthy patients are safe to extubate deeply, but this author is unconvinced of the benefit/risk analysis of deep extubation. You may make the surgeon happy, and you may continue to have a safe airway under general anesthesia in the absence of the endotracheal tube, but what if you don’t? What if the airway is poorly maintained in this patient after this five-hour surgery, when her entire head and jaw are wrapped up in a bulky facelift dressing? My advice is to take out the breathing tube when you’re ready, not when the surgeon asks you to.
  7. “Just give the patient a little bit of anesthesia, because my procedure will only last 10 minutes.” In an example of this scenario, the surgeon requests you sedate a 210-pound woman with a Body Mass Index (BMI) = 36 for a 15-minute egg retrieval. Because of the brief and seemingly trivial nature of the procedure, the gynecologist requests an anesthetic free of any airway tubes. You assess the patient and her airway, and decide you’ll need to use a laryngeal mask airway (LMA), with an endotracheal tube ready to go if the woman’s ventilation on the LMA is suboptimal. You explain to the surgeon that you’re doing what is safe, despite the requests the surgeon made. On obese, elderly, pediatric, or sicker patients, there are simple surgeries, but there are no simple anesthetics. Rely on your experience and training, and do the anesthetic by the standard of care.
  8. “I’d like to do this procedure in my office operating room, not in a surgery center or the hospital.” In an example of this scenario, the surgeon has a patient he’d only like to operate on in his office. You’ve worked at his office before, and you know his office operating room does not have an anesthesia machine. Your technique there is limited to IV sedation without any airway tubes or ventilation. You discover that the patient is an obese 45-year-old woman with a BMI = 32, and the planned procedure is implantation of a maxillary bone graft. Your concern is that you will not be able to safely sedate or anesthetize this woman for this oral surgery without a breathing tube or an anesthesia machine. The surgeon objects, and says that the woman does not have enough money to pay for the procedure to be done at the local outpatient surgery center, and that’s why he needs to do it in the office. You stand firm, and kindly refuse to do the anesthetic in his office.

 

 

WHEN PATIENTS TRY TO TELL THE ANESTHESIOLOGIST WHAT TO DO:

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  1. “I don’t want a breathing tube into my windpipe and voice box because I’m a singer and I don’t want my voice ruined.” In an example of this scenario, a 35-year-old 250-pound man with a BMI of 34 who sings in a rock ‘n roll band is about to have a lumbar laminectomy. He does not want to be intubated. He read about anesthesia on the Internet, and he wants you to use an LMA instead of an endotracheal tube. Your response? You advise him that per your experience and training, his only safe airway management is with an endotracheal tube, not with an LMA. You tell him that yes, he will have a sore throat after surgery, and the irritation to his vocal cords may cause a temporary hoarse voice. You advise him that the duration of the hoarse voice should be no more than several days or a week or two, and that it’s rare for any voice change to be permanent. You advise him that he can consent to the endotracheal tube with these risks, or he can refuse. If he refuses the appropriate airway tube management, you will decline to give him anesthesia today.
  2. “I want to be awake for my surgery, so I can watch and talk to the surgeon.” In an example of this scenario, a 55-year-old woman scheduled for a knee arthroscopy wants to be awake for the surgery. She is visibly nervous, and tells you she wants to be awake because she is afraid of dying during a general anesthetic. You discuss the options with the patient, which include spinal anesthesia, epidural anesthesia, or regional blocks, each accompanied by intravenous sedation if necessary, which will permit her to be comfortable and awake. She declines each of these. She just wants “some medicine in the IV to take the edge off while I’m still awake, just like I did with my last colonoscopy.” You discuss with her that knee surgery is more painful than a colonoscopy. You discuss with her that she will need more anesthesia than she is requesting. You leave the bedside and talk to the surgeon about the options. The surgeon is agreeable with injecting local anesthesia into the knee, as a supplement to the intravenous sedation you will administer. The patient, the surgeon, and you all agree with this plan. You also give the patient informed consent that if she is not comfortable, she may need more anesthesia medications from you and she may have to go to sleep. Begrudgingly, she consents. Five minutes into the surgery, despite 200 micrograms of IV fentanyl, 6 milligrams of IV midazolam, and appropriate 2% lidocaine injections into the knee joint by the surgeon, the patient is uncomfortable, crying, and in a state of panic. You begin an infusion of propofol, she goes to sleep, and the ordeal is over. She awakens in the PACU without complications and without complaints. In my experience, many patients who demand or insist on being awake during surgery are patients who hope to control circumstances in the middle of surgery, rather than trusting their anesthesiologist and surgeon. Don’t be surprised if these patients wind up requiring general anesthetics. Make sure you have preoperative informed consent for general anesthesia as a back up, because it’s likely you’ll need to administer it.
  3. A patient who’s been in the PACU (Post Anesthesia Care Unit) for an hour tells you, “I want more intravenous narcotics.” In an example of this scenario, a patient who had an arthroscopic anterior cruciate ligament (ACL) reconstruction is complaining of 8/10 pain ninety minutes postoperatively. He’s received 300 micrograms of fentanyl and two Percocet in the PACU, and says he is still uncomfortable. You go to his bedside, and witness that he is in no acute distress. His vital signs are normal, with a respiratory rate of 12 breaths per minute. He refused a femoral nerve block prior to surgery. Because he’s been medicated, the option of having him sign a consent and performing a femoral nerve block now is out of the question. Your assessment is that his pain score is inflated. One man’s 8/10 may be another’s 3/10. His respiratory rate is already low normal, and he’s received the adjunct of 30 mg of IV Toradol, as well as the Percocet. At this point in my practice I have the following conversation with the patient: I tell them, “You’ve already had the standard pain-relieving medications, including the oral medication the surgeon prescribed for home use. One option now would be to hospitalize you so that you can continue to receive IV narcotics, but we don’t hospitalize healthy patients after routine ACL reconstruction. A second option is for you to stay here in the PACU and continue to receive IV narcotics, but that makes little sense because you cannot continue IV narcotics at home. So the remaining option is for you to be discharged on the oral medication Percocet that the surgeon prescribed.” There’s a point after routine outpatient surgeries where there’s no rationale for the continued administration of IV narcotics, and the patient needs to be discharged home on their oral medications.
  4. Your awake patient in the PACU says, “I’m so anxious. Can I have more of that Versed you gave me before surgery?” In an example of this scenario, a patient with chronic anxiety wakes up from an uneventful anesthetic with complaints of nervousness. The role of the PACU staff is to monitor Airway-Breathing-Circulation while tending to common postsurgical complaints such as pain and nausea until the anesthetics wear off sufficiently for discharge. In my residency, my professors taught me that benzodiazepines were valuable preoperatively but have no role in the PACU, and I still follow this principle. The PACU is a temporary destination prior to discharging a patient home or to their hospital room. Sedating these patients with Versed or any other benzodiazepine in the PACU will prolong their recovery and is not indicated. The best treatment for PACU anxiety is often to discharge the patient out of the PACU.
  5. Your next patient is a child. His parent tells you, “I want to be in the operating room when my son goes to sleep. He needs me.” In an example of this scenario, the mother of a 3-year-old patient wants to accompany her son into the operating room to emotionally support the boy during a mask induction with sevoflurane. The scheduled procedure is bilateral ear pressure-equalizing tubes surgery. This author believes that parent(s) can be a distraction during the potentially dangerous time of mask induction of anesthesia. I’ve done thousands of pediatric inductions without parental presence, and I never wished I had a layperson there at my elbow while I was trying to assure safe airway management. Letting the child watch an iPad as they separate from their parents and engage in the anesthesia induction is a modern solution to this problem.
  6. A preoperative patient with a dangerous airway problem (think ankylosing spondylitis or Treacher Collins syndrome) tells you, “I refuse to have an awake intubation. I need the general anesthesia first before you put in that breathing tube.” In an example of this scenario, an 18-year-old boy with Treacher Collins syndrome and a very abnormal airway refuses awake intubation for an emergency appendectomy. Your assessment of his airway is that you will not be able to visualize the vocal cords with either traditional laryngoscopy or video laryngoscopy. You’re uncertain you can mask ventilate the patient if he is asleep either. You tell him he can be sedated and relaxed for an awake intubation, but you cannot administer general anesthetic prior to his intubation, for safety reasons. Per a study on this very topic, you decide to use dexmedetomidine , which has minimal respiratory depression, to sedate him, and you acquire the assistance of a second anesthesiologist to monitor the patient and manage the sedation while you apply topical anesthesia to the airway and drive the fiberoptic scope. After thirty minutes of work, the two of you manage to successfully insert the endotracheal tube, and the surgery can begin.

 

The overwhelming majority of anesthesiologist-surgeon and anesthesiologist-patient interactions are positive. But when conflicts such as these examples occur, the take-home messages are:

  1. YOU ARE THE BOARD-CERTIFIED SPECIALIST IN ANESTHESIA. IT IS YOUR JOB TO MAKE THE ANESTHESIA DECISIONS.
  2. SURGEONS ARE SPECIALISTS IN SURGERY. THEY ARE NOT SPECIALISTS IN ANESTHESIA OR PERIOPERATIVE MEDICINE.
  3. YOU PAY YOUR OWN MALPRACTICE INSURANCE, AND YOU HAVE TO ANSWER TO THE CONSEQUENCES IF YOU GET SUED. IF YOU ARE SUED, THE KEY QUESTION WILL BE “DID THE ANESTHESIOLOGIST PRACTICE AT THE STANDARD OF CARE?” REPLYING THAT THE SURGEON OR THE PATIENT TALKED YOU INTO A SUB-STANDARD PRACTICE IS NO DEFENSE. IT IS YOUR JOB TO MAKE THE ANESTHESIA DECISIONS.
  4. THE CORRECT ANESTHETIC PLAN IS THE SIMPLEST ANESTHETIC PLAN THAT ALL THREE PARTIES (THE SURGEON, THE PATIENT, AND YOU) AGREE TO.

 

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