I wish to relay a growing concern by many anesthesiologists regarding office-based anesthesia. Due to the fees that are paid for "facility" use with each surgery, more surgeons are performing operations in their offices. We may be the only "safety net" the patients have to limit what surgeons can and will do in these mini-operating rooms.

Our group has been asked to perform more complex cases and longer anesthetics with the retort that other surgeons are doing these cases in nearby cities as well. The horror stories are beginning to mount regarding office cases where judgment was overpowered by financial gain.

Somehow the public and the payers need to realize the trend may be neither cost-saving nor safe!

Kenneth Bachenberg, M.D.
Bellingham, Washington

As Chair of the Committee on Ambulatory Surgical Care, I received a copy of your correspondence expressing your concerns about office-based anesthesia. The ASA Committee on Ambulatory Surgical Care is currently developing guidelines that underscore the consistency of care and single standard in all ambulatory settings regardless of site.

We also have been contacted by the American College of Surgeons, the Joint Commission on Accreditation of Healthcare Organizations and AAAASF (the accrediting organization that accredits office practices) to collaborate on projects addressing safety and guidelines. Several of the committee members are also involved in legislative efforts within their own states.

Office-based anesthesia is a rapidly growing area, and ASA recognizes the need for maintaining standards and quality.

"Contaminated pharmaceutical products can result in substantial morbidity and mortality and should be included in the differential diagnosis of deaths of unknown origin." Thus begins an abstract in JAMA (1998; 279:1175).

The above referenced article reports on a series of pediatric deaths from acute renal failure following ingestion of acetaminophen syrup. Ultimately, the culprit was determined to be the glycerin syrup which was contaminated with significant concentrations of diethylene glycol, commonly used in automobile cooling systems as antifreeze. The syrup has been imported from China via Europe by the pharmaceutical manufacturer.

This morning I picked up an ampule of a widely used induction agent and noted it was manufactured overseas. The question arises as to how strict are the standards imposed on foreign manufacturers of materials we may be using.

Thank you for your provocative article "Physician-Assisted Suicide - A Sin of Commission or Omission?" in the March 1998 issue of the ASA NEWSLETTER. I agree with you that physician-assisted suicide (PAS) is one of the biggest ethical issues that organized medicine, including the ASA, will have to work through in our lifetimes. I want to share with you several thoughts on PAS.

First, Eric Erikson's theory of psychosocial development named the final stage (choice) "Integrity vs. Despair." As individuals we all have the responsibility not only to live with integrity but also to die with integrity. Integrity considers not only what seems best for me at the time, but also what influence for good or evil my choices will have on those who follow me. Do not those who promote PAS actually feed the flame of despair?

Second, there have always been and should always be prohibitions in medicine that are not up for a vote. The AMA's prohibition against physicians having sexual encounters with patients is one example. Similarly, the prohibition against PAS should not be considered a matter for the political whim of the day.

Third, we must never forget the atrocities that took place in this century in Nazi Germany in the name of euthanasia. Neither should we ignore the fact that, in spite of legal restrictions, involuntary euthanasia continues to occur today in the Netherlands.

Thank you for considering these thoughts.

After reading the "Letters to the Editor" (June 1998 ASA NEWSLETTER), I felt I must "add my two cents" regarding "the epidural saga."

After completing my residency at Detroit Osteopathic Hospital in 1959, I moved to Youngstown, Ohio, in 1960, which is midway between Pittsburgh and Cleveland. I became acquainted with epidural analgesia for labor and delivery during my residency. There were approximately 5,000 deliveries in 1958 at Detroit Osteopathic Hospital and more than 80 percent were managed with epidural analgesia.¹ While there were considerably less deliveries at Youngstown Osteopathic Hospital (about 400-500), the percentage of epidural analgesia was approximately the same, about 85 percent. It is also my recollection that Robert Hingson, M.D., was performing mostly caudal analgesia at the now defunct Women's Hospital of Cleveland, Ohio.

It is amusing as I reminisce that anesthesiologists in the surrounding hospitals in Youngstown were quite critical of my use of epidurals for labor and delivery. Even though this was in 1960, not 1970 as mentioned by Ezzat I. Abouleish, M.D., I really did not consider myself a "pioneer" in epidural analgesia considering the massive numbers performed at Detroit Osteopathic, not only by me, but by my associates and instructors. I continue to be a strong proponent of epidurals for labor and delivery, as well as for surgical and postoperative pain control.

Douglas M. Goldsmith, D.O.
Youngstown, Ohio

Having read the two letters regarding epidural anesthesia (June 1998 ASA NEWSLETTER), I am prompted to write briefly of my own personal history with this technique.

On my return to Canada in 1957 after postgraduate training in anesthesia at the University of Maryland, Baltimore, Maryland, I was appointed to the staff of the new Mount Sinai Hospital in Toronto. The appointment was conditional on my learning epidural anesthesia for obstetrics, as I had performed epidurals on only one or two occasions during my residency. Needless to say, I did master the procedure very quickly as the hospital had a very busy obstetrical service for which twenty-four hour coverage was provided.

In 1958, our group, of which I am the sole surviving member, published "The Routine Use of Lumbar Epidural Anesthesia in Obstetrics" in the Canadian Anaesthetists' Society Journal. Our single-shot technique involved the use of the Tuohy needle. Catheters were not available, although from time to time we did improvise by using a ureteral catheter. Our publication, which demonstrated the safety and practicality of the technique, attracted many residents who trained with us.

Edward J. Sheffman, M.D.
North York, Ontario, Canada

Epidural Saga Continues: III

Richard B. Clark, M.D., has recently reported on the initiatives of Robert Hustead, M.D., and Ezzat I. Abouleish, M.D. The latter's history and contributions were included and supported by an autobiographical letter. The ASA NEWSLETTER Editor received letters from my colleagues Brett B. Gutsche, M.D., and Theodore G. Cheek, M.D., neither of whom was privy regarding the institution of epidurals at Magee-Women's Hospital, and Amr E. Abouleish, M.D., was a child at that time. My responsibility, as Chief of Anesthesia, was to formulate and direct policy while Dr. Abouleish, who was Director of Obstetric Anesthesia, was responsible for the practical duties performed.

I do take exception to false claims. The pioneer of the double catheter technique was an obstetrician, John Cleland, M.D., who practiced at his Portland Clinic in Portland, Oregon. In 1970, I had visited with him and his son in Portland to review their practice. Double catheter insertion was the method of choice for their obstetric service and most major gynecologic operations.

Ray McKenzie, M.D.
Pittsburgh, Pennsylvania

While Dr. Abouleish should be given the medal of honor for his work in obstetrical anesthesia, we cannot and must not credit him with introducing continuous lumbar epidural anesthesia to the United States. Undoubtedly he introduced this modality to the Magee Women's Hospital in 1970.

I do not intend any disrespect for Dr. Abouleish's contributions to anesthesia. My only concern is for historical accuracy - since I am the only author of our original contribution left to respond.

Benson Bodell, M.D.
Houston, Texas

1. Epidural Anesthesia for Cesarean Section. New York State Journal of Medicine. 1952; 52:1901-1905.
2. Continuous segmental thoracolumbar epidural block. Anes Analg. 1953; 32:73-89.
3. Epidural anesthesia: Clinical evaluation of drugs used in obtaining, Lumbar. Anesthesiology. 1955; 16(3):386.
4. 2-Chloroprocaine (Nesacaine)-Its relative nontoxicity as demonstrated by epidural anesthesia. AMA Archives of Surg. 1959:75-78.
5. Epidural anesthesia for cesarean section: A report of 800 cases. Anes Analg. 1964:452.

I am following with amusement the current controversy unfolding in the ASA NEWSLETTER.

Finally, the paying agents in the United States have listened to what a significant part of the ASA membership has told their colleague surgeons for many years. Those anesthesiologists have "told" them from their actions that the care of the supervised/employed certified registered nurse anesthetist (CRNA) was as good as their own care. They have told surgeons by letting CRNAs replace them at the patient's side while anesthesiologists were remotely supervising one or many of them. They have told them as John A. Kemp, M.D., Ph.D., stated in his letter in the June 1998 NEWSLETTER that CRNAs could deliver care at night for their patients while they were home in bed. They have told it as Patricia R. Evans, M.D., stated in another letter in the same issue by running a stable of CRNAs. Why has this happened? Yon Ough, M.D., Steve Choung, M.D., and Robert Courish, M.D., in their letter tell you: easy money and lessened workload.

For me, this can be easily equated to greed and sloth. Furthermore, in many eyes, ASA has given credence to all of the above by allowing these supervisory practices. Now anesthesiologists and ASA leadership are wondering why the paying agents want to act on this obvious conclusion. If U.S. anesthesiologists believe that CRNA's work is as good as theirs, why should not the payers cut the middlemen as Dr. Evans described in her letter? Why blame them when they believe that the superfluous middlemen are the more expensive "supervising" anesthesiologists and not the CRNA who is doing the actual work? Anesthesiologists have cheapened their profession in the eyes of their peers for the sale of "easy money and lessened workload." They are now reaping what they have sown. The only way to resolve this problem is for ASA to discourage the current practice of CRNA supervision. In essence, return to direct care of their patients.

Dr. Kemp's claim in the June 1998 ASA NEWSLETTER that his group's obstetrical practice is unique in the state of Washington should not come as a surprise to anyone.

His description appears to be in conflict with at least six of the Standards and Guidelines espoused by the ASA. These include:

• Basic Standards for Preanesthesia Care (Standard #1)
• Guidelines for the Ethical Practice of Anesthesia
  (Definitions)
• Guidelines for the Delegation of Technical Anesthesia Function to Nonphysician Personnel (I, II)
• Guidelines for Regional Anesthesia in Obstetrics (II)
• Guidelines for Patient Care in Anesthesiology (III)
• Anesthesia Care Team (#1)

Most of these conflicts revolve around the definition of medical supervision where the words "personal" and "participate" are frequently used.

But even if Dr. Kemp is comfortable that the requirements for medical supervision are met, there is clearly a dual standard of care. In his letter, he describes direct physician participation during the day but not at night or on weekends except in a back-up or consultative manner. This is in direct conflict with Section III (A) in the Guidelines for Patient Care in Anesthesiology, which requires the same quality of care at any time for all groups of patients.

Neither is it very surprising that the obstetrical staff "militantly defend" this arrangement. After all, the CRNAs are responsible for 50 percent more hours per week than the physicians. In addition, the CRNAs take the night and weekend calls that most consider to be far more onerous than the regular day work, especially in obstetrics, which is the specialty that is the least amenable to a regular schedule. Indeed one of the major stumbling blocks in developing an obstetrical analgesia service is the "after hours" staffing requirements.

This issue is not about the mode of delivery of anesthesia care, "anesthesia care team" as opposed to "physician only," or even whether CRNAs should or should not administer regional anesthesia/analgesia but a more fundamental issue, namely, scope of practice.

I read Dr. Kemp's letter on the plane home from the ASA Legislative Conference where the major issue was HCFA's proposal to remove the medical direction requirements for nurse anesthetists to "facilitate administrative flexibility." It is quite devastating to read a letter like this after spending several days working to convince our legislators that anesthesiology is, indeed, the practice of medicine. Such practices described by Dr. Kemp lend great credibility to the CRNAs' claim that they only need the physician on a p.r.n. basis and are quite capable of independent practice.

It is indeed true that "our worst enemy is us."

Vigilance

At first glance, the cover of June 1998 ASA NEWSLETTER, appeared to be a high-tech research lab result. However, when one appreciates its significance, it does become a work of art. Taping of the eyelids is a prime example of vigilant care. It is also common sense, which is the rarest type of sense there is. My Dad used to call it "horse sense," which he defined as "stable thinking." Kudos to Dr. Millbern.

After a 30-plus-year career as an anaesthetist in Australia, in 1982, I commenced the first full-time palliative medicine service at the Sydney hospital, where I had been the Chief of Anaesthesia, and directed it for five years. As a result of my experiences with dying people, I am an active opponent of euthanasia and physician-assisted suicide (PAS).

Briefly, here are some of the errors, subtle and otherwise, in the common arguments in favor of medical killing:

1) Since neither pain nor suffering is objectively measurable or comparable between persons, they cannot be used to ground safe, effective, consistent public policy.

2) Suffering is an unavoidable part of the human condition. Being a psychological response to any situation that threatens the well-being, it has no specific relevance to physicians, except where illness is the cause. So, without realizing it, physicians are being expected to rid the community of persons whose problems may be largely social.

3) There are two sets of autonomy to the patient's right to self-determination, one of which is being ignored. Once the patient has asked the physician, it is the latter's separate choice, to agree or not, that decides whether euthanasia or PAS will ever occur. In every instance, it is the physician's autonomy that prevails, while he/she has the undoubtedly larger measure of power in the relationship.

4) The patient who asks for death will have decided subjectively that his/her life is no longer worthwhile, but there are no objective criteria to enable every observer to reach the same conclusion. Ultimately, the physician's view will be the result of his/her personal values and, therefore, will be subjective, making the process a kind of lottery of life.

5) A legal requirement that the physician will give the patient all the details necessary to enable an informed choice would be useless, unless there was an expert witness present on each occasion to detect possible bias, inaccuracy, ignorance, adequacy or coercion.

6) A legal requirement that the physician was satisfied that the patient was not being unduly influenced would be similarly useless. There are no ways in which coercion could be detected, especially if the parties wanted it concealed, and they usually would.

7) It would surely be unacceptable to take life to relieve distress if effective relief was available by less drastic means. If a patient refused them and insisted on being killed, that would be evidence of suicidal intent. Unless all the details about the medical treatment of a person for whom killing was proposed were expertly scrutinized in advance, it could never be known whether it was justified, and whether the physician was acting responsibly.

8) The sustained wish to be dead is abnormal, even in the terminally ill. It is consistently found to be associated with unrelieved distressing symptoms, a previous history of attempted suicide or depression, lack of social support or a present psychological illness, usually depression.

9) The slippage from voluntary to nonvoluntary euthanasia is the most dangerous and unwelcome consequence of approved voluntary euthanasia and must be regarded as likely, if not inevitable.

I wish you well in your efforts to bring some balance into the debate, of which too much has been carried on to the neglect of ethical, medical and legal basics.

I submitted a letter to the Health Care Financing Administration in response to their recent proposed change in the Medicare and Medicaid requirements for physician supervision of nurse anesthesia providers. Recently, I became aware that a copy of this letter was being circulated among the nurses at my institution (a government facility).

It is enlightening to realize how aware the nurses and their society are about what we anesthesiologists say and do. I am certainly not as well-informed about their efforts in the political arena. I believe that if part of the energy the nurses spend politicking was applied to furthering their educations, they could reach their goal of independent practice - as duly licensed physicians. I obtained my right to practice my profession independently by going to medical school and completing a residency, not by attempting to change well-established civil and administrative laws.

The views and opinions expressed in the "Letters to the Editor" are those of the authors and do not necessarily reflect the views of ASA or the NEWSLETTER Editorial Board. Letters submitted for consideration should not exceed 300 words in length. The Editor has the authority to accept or reject any letter submitted for publication. Letters must be signed (although name may be withheld on request) and are subject to editing and abridgment.

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