November 2001
Volume 65 |
Number 11
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| LETTERS TO THE EDITOR |
Finding Time for Subspecialty Care
As an academic anesthesiologist/intensivist splitting my time
between anesthesiology and pediatric critical care, I enjoyed
the articles in the August 2001 NEWSLETTER pertaining to
critical care. But I think there are many reasons that I am only
one of 900 anesthesiologist-intensivists among 9,000 from other
specialties. Medical students choosing anesthesiology are usually
attracted by the intense but predictably brief patient contact
of the operating room. That is not a criticism, but it accurately
predicts that few anesthesiology residents would seek the ongoing
(often socially complex and emotionally challenging) patient and
family contact, lengthy differential diagnoses and often frustratingly
slow therapeutic responses of intensive care unit patients.
Further, intensivists from other specialties can provide economical
continuing care beyond the intensive care unit, even to the ambulatory
clinic — something few anesthesiologists can provide.
Although the incomparable airway management that all anesthesiologists
should provide, and the expert pain management that some can provide,
may help selected intensive care patients, neither those skills
nor the systems and safety knowledge of our specialty are the
essence of critical care. That essence is defined not only by
the fundamentals but also the arcana of internal medicine and
pediatrics, topics often merely tangential to the daily work of
most anesthesiologists.
Although many of us find it wonderfully rewarding to practice
the two specialties simultaneously, I do not think most of us
see one as flowing naturally from the other. Rather, we accept
limitations on our anesthesiology practice while we struggle to
maintain competency and currency in two very different and equally
demanding specialties.
Critical care pep talks to anesthesiology residents probably
do no real harm, but they will have little impact.
Thomas J. Poulton, M.D.
Omaha, Nebraska
Raising Better Consciousness About Sedation
Guidelines
I would like to offer another perspective on “conscious
sedation” and the comments made by John M. Freedman, M.D.,
and Mark J. Lema, M.D., Ph.D., in the “Letters to the Editor”
section of the September 2001 ASA NEWSLETTER. Dr. Freedman
argues, and many have agreed, that the term “conscious sedation”
be abandoned. Hence, the development of the more logical terminology
created by ASA and adopted by the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO), which defines the continuum
of sedation from “least” (minimal) to “most”
(general anesthesia) with “moderate” and “deep”
in between. Dr. Freedman’s call for the term “procedural
sedation” to supplant “conscious sedation” is unnecessary
and potentially confusing. The new definition of moderate sedation
is very functional. In addition, sedation is administered for
diagnostic tests, too. Creating a definition that links what the
patient is undergoing (e.g., procedure, test) risks fragmentation
of the well-conceived new definitions.
Dr. Lema comments that the administration of sedation by nonanesthesiologists
is a compromise associated with added risks for patients. As a
cardiac anesthesiologist, this perspective reminds me of the cardiologists
perceiving my performance of transesophageal echocardiography
as inevitably substandard. Regardless of how much of a compromise
exists, there are certainly not enough anesthesiologists and/or
nurse anesthetists to administer all necessary sedations. Even
if there were, who would pay for all this additional service?
As the liaison individual for sedation issues within my hospital,
my approach is to emphasize the now standardized terminology,
but, for the time being, couple it with the old, as in “moderate
(conscious) sedation.” The real work for anesthesiologists,
however, is to take a proactive role and do more than help their
hospital when JCAHO comes to town. Anesthesiologists need to help
educate and train their colleagues (we should stop calling them
nonanesthesiologists) so that they too can administer safe and
effective sedation. Toward that end, I have put together a one-day
course as well as an ongoing simulator-based course to credential
individuals for moderate sedation. These courses help interested
clinicians acquire and test much of the knowledge and skills related
to moderate sedation. I believe that these types of efforts are
what will really help patients.
Peter L. Bailey, M.D.
Rochester, New York
‘Mickey Mouse,’ ‘Alexis
de Toqueville’ Reap Benefits of Supermarket Bonus Card
I enjoy Dr. Lema’s “Ventilations” and just had
to comment on the September installment. While I, too, think it
is ridiculous to provide personal information in return for a
supermarket “bonus card,” there is certainly no reason
that you can’t get the card without providing the information.
My favorite cashier at the local Safeway tells me that there are
thousands of Mickey Mouses in their files, though I am the only
Alexis De Toqueville that she knows of. The supermarkets out here
readily acknowledge that you really just need to fill in any seven-digit
number under “telephone number,” and the rest can be
left blank.
Unfortunately, accommodating the the Health Insurance Portability
and Accountability Act won’t be as simple.
David M. Joseph, M.D.
Tucson, Arizona
Thanks to Those Who Scripted Our Success
I enjoy reading your “Ventilations.” You always have
pithy comments that are quite pertinent to the every day life
of the anesthesiologist.
I was working in an operating room the other day with a gynecologist.
Somehow the conversation turned to the good care we give our residents
by giving them breaks, lunch, letting them go home after call,
etc. He then turned to his resident and said, “You know,
these anesthesiologists are really smart. When managed care came
in years ago, they closed a bunch of their residencies to keep
manpower down. Sure, they worked hard for a couple of years, but
now they are in the driver’s seat. They are in demand. Their
salaries are great. They are so smart!”
I must say I had never heard that spin put on our situation of
several years ago. Could it be that this is how the rest of medicine
sees us? Great tacticians? If this is the “truth,” I’d
like to commend the private practitioners among us who temporarily
closed down the job market, the academicians who continued training
and wooing whatever medical students came our way under severe
constraints, the “powers that be” who thought up the
whole idea and all of us who worked ourselves to the bone waiting
for the turnaround!
Saundra E. Curry, M.D.
Chappaqua, New York
Editor’s Note — We can’t even get
everyone to agree on the severity of the nurse anesthesia assault
on the practice of medicine, so to think that this crisis was
contrived and well-executed is mere folly. The Federal Trade Commission
and the nurse anesthetists’ organization would have been
“all over us like white on rice!”
It has been part of anesthesiology’s history
to live from crisis to crisis. The last drought occurred in the
early to mid-1980s. What may make this shortage unique is the
concurrent shortage of nurse anesthetists in an aging and surgically
expanding environment. At least we are not driving taxis like
the deans predicted, which started the downward spiral of residency
positions.
— M.J.L.
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