Medicine
Could Learn a Lot From Team Sports
As an elderly anesthesiologist now having practiced
in the specialty for over 34 years, I have heard most
of the opinions as to the “captain of the ship”
arguments. It seems to me that we might consider the
following thought:
Medicine is not a competitive sport! Medicine is a cooperative
endeavor!
It has been my responsibility to have this discussion
with a number of colleagues in my own specialty, all
the surgical fields and many of the medical ones. Circulating
nurses and technicians have tired of hearing it. The
truth remains, however, that far too many of us went
through our training in situations that were adversarial
as to interdepartmental relations.
Neither the anesthesiologist, the (gasp) surgeon, the
circulator, the technician nor the administrator has
nearly the importance as that poor soul who is actually
lying on that table.
If you have to give an extra, small amount of muscle
relaxant, or if the surgeon has to make do with less
Trendelenburg (or even let some of the carbon dioxide
out of the belly for you), this can be accomplished
cooperatively.
The benefits of the experience will accrue to all of
you.
Tom P. Roberson, M.D.
Roswell, Georgia
Maybe
General Anesthesia Should Be Put to Sleep
Dr. Lema has sounded an appropriate alarm about regional
anesthesia (RA) in his August
2002 “Ventilations”
by pointing out the seemingly over-riding concern of
surgeons and O.R. administrators to be most cost-effective.
He addresses the important issue of postoperative pain
and stresses the physiological advantages of RA on clotting,
etc. I should like to add a further advantage: the ablation,
or amelioration, of the neurohumoral stress response.
Significant health and cost concerns are postoperative
complications, especially infection and CV abnormalities,
which may be facilitated by the debility brought about
by the physiological stress of surgery. Has any consideration
been given to the hypothesis that general anesthesia
(GA), by rendering the patient “apparently”
insensible to pain but not actually reducing the physiological
stress response, makes the patient more susceptible
to infection? What of the hypothesis that GA actually
depresses the immune response? After all, why is infection
more common in postoperative patients than in the general
population? The answer must consider disease, surgery
and the anesthetic technique and agents. I believe there
are many advantages of RA to patients, and these need
to be explained to them as part of informed consent.
Surgeons recognize the need to explain benefits of alternative
methods of treatment to the one proposed, and so should
we.
As physicians, our objective should not be to move patients
more quickly through the “cost center” of
the O.R., but to obtain a good (not necessarily perfect)
physiological result. I encourage research into immune
modulation by GA.
Anthony J. Adolph, M.D.
Austin, Texas
Whose
Side Are you On?
The article “Understanding
the New Aetna” in the August
2002 NEWSLETTER is infuriating to me, a “front-line”
private practice anesthesiologist, for its favorable
portrayal of Aetna. I am on the Management Committee
of one of the largest private practice groups in New
York state. My experience, along with several of my
colleagues, has been and continues to be significantly
appalling with respect to Aetna. The fact that ASA does
not appreciate such is even more worrisome.
Here are some actual examples of the “New Aetna.”
In the New York City area, Aetna continues to be one
of the lowest managed care payers; less than GHI or
HIP. Aetna deliberately did not sign a renegotiated
and completed contract with one New York state group
for more than three months simply so that the old fee
structure could be utilized a little longer. Aetna continues
to refuse to pay one New York state group for the anesthesia
services at an institution because it claims to have
had a contract with the previous group, which reimbursed
$197 per case directly to the hospital. That old group
is not even in existence anymore.
The fact that an anesthesiologist is part of management
or that a managed care company publishes its policies
is not worthy of a laudatory article in the ASA
NEWSLETTER. ASA should be a forceful representative
of its membership, not a handmaiden to others.
Roland R. Rizzi, M.D.
Rye, New York
Editor’s Reply: I am somewhat
disappointed in the letter above from Dr. Rizzi and
from Melvin J. Bush, M.D. (“Reader
Not Glad He Met Aetna,” October 2002).
Both letters personally attacked a member of the ASA
staff who works diligently for all ASA members. Her
column is one of the most informative pieces for the
practicing anesthesiologist. While Aetna (and all HMOs)
do not have a level playing field, it is still within
her purview to report any positive changes that may
have occurred with Aetna (See
page 27 of the October 2002 NEWSLETTER).
In the future, I suggest that one states the contrary
evidence without a personal attack — save those
for my editorials!
Reader Has Gimlet Eye
for Neuromuscular Function Monitoring Facts
The introductory sentence of the article
by John J. Savarese, M.D., in the
September 2002 NEWSLETTER, in which he reviews
the monitoring of neuromuscular function, is a significant
distortion of the history of neuromuscular blocking
agents. Not all agents were long-acting until the 1980s.
It should be recalled that the use of d-tubocurarine
was minimal in the 1940s and 1950s. Its use decreased
further after the Beecher-Todd report of the mid-1950s.
Succinylcholine, by bolus or by continuous infusion,
was the primary muscle relaxant in use for at least
two decades prior to the introduction of the “Block-Aid™
Monitor” and the newer nondepolarizers. Indeed,
Ronald A. Katz, M.D., who is quoted by Dr. Savarese,
speaks to the continuous use of the “Block-Aid
Monitor” when “a continuous succinylcholine
drip technique is used.”
Howard L. Zauder, M.D., Ph.D.
Scottsdale, Arizona
Why Should Life Be All Labor
for OB Anesthesiologists?
Joy L. Hawkins, M.D., gave a very nice report on the
American College of Obstetricians and Gynecologists
(ACOG) pronouncements regarding vaginal birth after
cesarean delivery (VBAC) in her September
2002 NEWSLETTER article.
She did not, however, specifically mention the pressures
that may be brought to bear on anesthesiologists with
obstetric practices (especially those with small obstetric
units).
Obstetricians may bring forward the issue that some
insurance companies mandate a trial of VBAC and that
ACOG recommendations effectively require an anesthesiologist
in house for such a trial. Their conclusion may be that
it is the responsibility of the anesthesiology department
to provide such coverage. It should be clearly understood
that the obstetrician’s relationship with insurance
companies and ACOG does not create a requirement for
us to supply uncompensated service. Dr. Hawkins did
emphasize that VBAC is an elective procedure.
On the issue of the Association of Women’s Health,
Obstetrics and Neonatal Nurses pronouncement that registered
nurses should not adjust epidural infusion rates: I
believe that was taken from material put out by the
American Association of Nurse Anesthetists, probably
with the intention of making it more difficult for anesthesiologists
to provide labor epidural services.
David Hunt, M.D.
Roanoke, Virginia
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