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May 1999
Volume 63 |
Number 5
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LETTERS TO THE EDITOR
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| Speaking Up About
Anti-Abortion Web Site |
Thank you for the excellent and courageous editorial in the December
issue of the ASA NEWSLETTER, "A Shot Through the Heart
of Personal Freedom." I am afraid that the article from the American
Medical Association (AMA) that followed in the NEWSLETTER
"...Actions to Stop Violence Against Physicians" was not very
reassuring. The AMA had crisis team members telephone physicians
listed on an anti-abortion Web site. If I were one of the physicians
learning that I was on an anti-abortion hit list, I imagine that
it would only increase the fear of violence that I feel. Isn't
this what the anti-abortion terrorists want? What is being done
about the list itself and the groups that produce it?
Finally, what can be done to encourage physicians to speak up
more in support of their colleagues as you have?
Lena Dohlman, M.D.
Brookline, Massachusetts
Editor's Reply: This violence against physicians goes
beyond the abortion issue. As seen in the American Medical News,1
a general surgeon who did not perform abortions was killed by
a disgruntled patient. One month prior to this incident, a psychiatrist
was shot by a psychiatric patient. The article offers some suggestions
for protecting one's self.
- M.J.L.
Reference:
- Shelton DL. Professional Issues: Recent murders reawaken
physicians' safety concerns. American
Medical News. 1999; 42(5):7-8.
Simulation in Anesthesia Training - Another
View
I agree wholeheartedly with H. Douglas Roberts, M.D., that many
newly trained anesthesiologists lack appropriate capability in
managing an airway with a mask ("Patients Are Not Mannequins or
Computers," December
1998NEWSLETTER). There are likely several reasons for
this, such as the introduction of the LMA, and as a result, we
share a concern that certain basic skills are being lost. He also
appears to be concerned about the use of anesthesia simulators
and their effect on training.
I believe his comments regarding the use of anesthesia simulators
represents a misunderstanding of their purpose. Simulators have
not been developed to replace the live patient for learning about
physiology and pharmacology, nor do they purport to do so. In
fact, I am not aware of anyone who suggests this. Simulators have
not been developed to replace "live patient experience in the
'middle of the night' situations." In fact, it is exactly this
sort of situation that simulator training is meant to enhance.
Simulators in anesthesia are finding a number of applications,
ranging from medical student education in anesthesia and orientation
of new residents to training in crisis management. By providing
exposure to rare or infrequent events, trainees can now practice
the management of such events before they happen for real, especially
since they may not even occur during a resident's training. As
is the case in other complex, dynamic domains such as aviation,
simulation is an important way to provide exposure to such events
and should enhance the ability to manage them. Additionally, simulators
are ideal for training in the management of perioperative critical
incidents (crises) such as may occur in the middle of the night.
In crisis training, in addition to using technical skills and
medical knowledge, trainees are taught appropriate crisis management
behaviors such as decision-making, workload management, teamwork
and communication skills. These types of training are what simulation
is all about, and where its greatest value appears to lie.1,2
I hope my comments better illustrate the role of simulation
and its value in anesthesia training. It is a tool that can improve
our skills at managing complex cases, and should not be seen as
replacing other learning modalities.
Richard Botney, MD
Portland, Oregon
References:
- Gaba DM, Howard SK, Flanagan B, Smith BE, Fish KJ, Botney
R. Assessment of clinical performance during simulated crises
using both technical and behavioral ratings. Anesthesiology.
1998; 89:8-18.
- Howard SK, Gaba DM, Fish KJ, Yang GS, Sarnquist FH. Anesthesia
crisis resource management training: Teaching anesthesiologists
to handle critical incidents. Aviat Space Environ Med.
1992; 63:763-770.
To Say We Practice 'Medicine' Is an Affront
to Anesthesiology
As a practicing anesthesiologist I am both horrified and amazed
that in December 1998 the AMA needs to declare "Anesthesiology
Is the Practice of Medicine." I view it as insulting that at this
point in the history of our specialty the question is even asked.
Does anyone still ask if obstetrics or surgery is the practice
of medicine?
I suspect the ASA's motivation for submitting the resolution
to the AMA House of Delegates was that when passed it would be
used as ammunition in the nurse anesthetist supervision debate.
I wonder if, as a specialty, we should better focus our attention
toward increasing our direct participation level when practicing
within the anesthesia care team model. I also wonder if
it is in our best long-term interest to discuss within the physician
anesthesia community the possibility of altering or even abandoning
the care team model.
We should not need an AMA resolution to state the obvious. It
tells me that as a specialty, we may need to modify our practice
patterns so this question never arises again.
Jordan H. Sankel, M.D.
Santa Fe, New Mexico
Back Up Words With Actions
I read the AMA resolution and the accompanying article by Ronald
A. MacKenzie, D.O. The words are nice but what good are they unless
they are backed up by actions. Here are some of the things I observe
that I believe degrade our status as physicians. First, I see
my colleagues asking nonphysician technicians what kind of anesthesia
they should administer to a patient. Also, we are called without
proper consultation, by the nurses, to provide institutional services
usually provided by technical staff when that staff is not available.
And don't all of us carry out orders written in the chart by other
physicians? Isn't that the duty of the nursing staff? If we continue
to act like technicians and perform the tasks usually carried
out by support staff, it makes it more difficult for anesthesiology
to be seen as the practice of medicine.
Name withheld on request
Pointing a Finger at Pulse Oximetry
I noticed with some concern the front cover of the February
1999 ASA NEWSLETTER. Prominently displayed was a "clothespin-type"
pulse oximeter on the second digit of a patient's hand. In my
experience, this is typically where such pulse oximeters are placed
by a wide variety of caregivers throughout this country. This
front-page display, unfortunately, reinforces what I consider
to be this less than optimal practice. When thus placed on the
index finger, the partially sedated and/or disoriented patient
may attempt to wipe an eye or scratch a facial itch, with the
potential that he/she could poke themselves in their eye with
a large plastic object (before even alert caregivers may be able
to intervene). In addition, I have found many of the recent brands
of "clothespin-type" oximeter sensors to exert too much pressure
and in fact cause some sustained soft tissue hypoperfusion of
the digit. For both reasons, I would suggest that consideration
be given to routine placement of digital pulse oximeter probes
on the fifth (or fourth) digit which may avoid these potential
problems.
Carl Lynch III, M.D., Ph.D.
Charlottesville, Virginia
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. Personal correspondence
to the Editor by letter or e-mail <Newsletter_Editor@ASAhq.org>
must be clearly indicated as "Not for Publication" by the sender.
Letters must be signed (although name may be withheld on request)
and are subject to editing and abridgment.
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