Rethinking Anesthesia Care During MRI

It may be appropriate for ASA and the Anesthesia Patient Safety Foundation (APSF) to specifically address monitoring standards for the provision of anesthesia during magnetic resonance imaging (MRI). At a refresher course earlier this year in California, I specifically asked if it was appropriate to monitor the patient, not from the scanner room itself (where the patient is in the scanner tube), but from the scanner control room (the room next door and 40 feet away). This question was answered by those in attendance, with more than 50 percent of the attendees indicating this was their practice: NO provider remained in the scanner room with the patient, whether they were M.D.s or nurse anesthetists. This is quite in contradiction to ASA’s “Standards for Basic Anesthetic Monitoring,” which make no provision for such exception:

STANDARD I
Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics and monitored anesthesia care.

In the past decade, I am aware of two deaths locally using these “40 foot/next door” techniques: 1) the expiratory limb of a circle system occluded and the patient succumbed to tension pneumothorax and 2) a mini-drip infusion of propofol (no volumetric pump) ran uncontrolled with a fatal outcome. Astonishingly a picture of a minidrip propofol infusion (without volumetric pump) of this kind, as well as “monitoring from the scanner control room,” is pictured in a recent MRI-anesthesia review article.¹ More astonishing is that modern MRI suites continue to function with antiquated equipment, although modern and MRI-compatible operating room suites have been introduced in the United States and Europe!^2,3

In conclusion I personally feel a need for specific modern national standards for MRI anesthesia that meet general published operating room guidelines to ensure safety and possibly facilitate the acquisition of appropriate equipment in financially trying times. Anesthesia safety should not be compromised by historic patterns and unfounded fears enticing a personal reluctance to remain at the side of the patient. The separation of anesthesia providers and equipment from the patient’s side in MRI should be relegated to the annals of history.⁴

Paul M. Kempen, M.D., Ph.D.
Wexford, Pennsylvania


References:

1. Gooden CK, Dilos B. Anesthesia for magnetic resonance imaging. Int Anesthesiol Clin. 2003; 41(2):29-37.

2. Hall, WA, et al. Safety, efficacy and functionality of high-field strength interventional magnetic resonance imaging for neurosurgery. Neurosurgery. 2000; 46(3):632-642.

3. Schmitz B, et al. Anesthesia during high-field intraoperative magnetic resonance imaging experience with 80 cases. J Neurosurg Anesthesiol. 2003; 15(3):255-262.

4. Menon DK, et al. Magnetic resonance for the anaesthetist. Anaesthesia. 1992; 47:240-255.

No Negotiating This Time

I recently read your article “Me vs. We” in the January 2005 ASA NEWSLETTER and was aghast. Your statement that there is a “deal” being negotiated with the federal government regarding eliminating the time factor in our compensation is extremely disturbing. Your statement regarding the slow surgeons is only part of the equation why time should be non-negotiable. The extreme variability in the length of cases is not only surgeon-dependent, but patient-dependent also. The most important factor to me is that we have no control over the time we spend with our patients. We are at the mercy of the surgeons.

I have been in practice for 22 years and remember when we were threatened with the prospect of diagnosis-related groups (DRGs). Because of our strong leadership at the time and the help of the American Medical Association, the DRG model for physician reimbursement was avoided. As you mentioned in your article, the elimination of the time factor would be devastating for teaching institutions. I also think it would be very naïve to think that the government would make us whole with any “deal.” We as a organization should do what is best for us and not what the payers think is best.

Your thinking that the question is “not if, but when,” is very short-sighted and ill-fated for our specialty. With that kind of thinking, we would have DRGs, and the hospital would be paying us. I think we need strong leadership and resolve to avoid this “deal.” I think the time factor must be non-negotiable, and any other outcome is unacceptable.
 
Roger C. Stuart, M.D.
Portland, Oregon

We Don’t Need This Kind of Hero

In the letter “Operation Hero” published in the January 2005 ASA NEWSLETTER, Robert E. Ploss, M.D., describes his hero, Richard N. Terry, M.D., who, when the surgeon commented that the patient was “a bit tight,” injected the curare through the I.V. tubing onto the floor and then asked the surgeon, “How’s that?”

In other words, Dr. Terry faked his surgeon. He could have said to the surgeon, “I know. I just injected more curare. It will take a couple of minutes to take maximum effect.”

I can just imagine any surgeon-to-be who saw what Dr. Ploss saw or reads this letter about a “hero.” It would have been much more heroic to play the scene straight.

Lawrence D. Egbert, M.D.
Baltimore, Maryland

Editor’s Note: As much as I respect Dr. Egbert, he has made a common historical error called “presentism,” which means putting present day values on an incident from the past and then making a judgment about it. Without knowing the surgeon, it is impossible to tell if Dr. Terry’s actions were fallacious. In point of fact, when this incident occurred in the early 1950s, there was a very different relationship between surgeon and anesthesiologist.

—D.R.B.

Dress for Success, or the Joke’s on You

I n response to Dr. Bacon’s article in the February 2005 ASA NEWSLETTER, let me assure my colleagues that how we comport ourselves does really matter. Having been in private practice for nearly 10 years, I have served my hospital in several capacities. I have served as chief of staff and chief of surgery and I am currently serving on my hospital board of governors. I serve on numerous committees.

In my community, there is no doubt about our specialty or its relevance. Let me also state the obvious. Being active in community affairs is vital. The advancement of our specialty takes place outside the operating room as well. We cannot succumb to cynicism or merely cloister ourselves away inside the confines of the operating room.

And, yes, there is a schism or two in our specialty. International medical graduates/American medical graduates, M.D./nurse anesthetist — you name it, we got it. This does not matter. We are judged as individuals by our surgeon colleagues. We need to dress the part, and we need to act the part. We owe this much to our patients and to our sense of professionalism. We as a specialty need to get rid of any chips on our shoulder. We are equals. Plain and simple. No more, no less.

Let me also say that ASA is far from perfect (not that it claims to be). It needs to listen more closely to private practitioners. Most of us are far removed from the academic environments of our residency days. Many of us perceive ASA to be completely out of touch with the average ‘working stiff” anesthesiologist.

One final point is worth mentioning — humor. I observe so many of my fellow colleagues as completely humorless and void of any pleasant affect. Smile every once in a while! It is a blessing just to be above ground.

Daniel F. McCarthy, M.D.
Washington, Indiana

Erratum
The letter to the editor titled “Reflection of a ‘Foreigner’” in the February 2005 NEWSLETTER was inadvertently listed as an anonymous letter, which was not the authors’ intent. ASA members C. O’Moore S. Smith, M.D., and Rosemarie A. Ferrer-Smith, M.D., of Kailua-Kona, Hawaii, wish to inform the readership that they were the authors of the aforementioned letter.

Dr. Cork’s Response to Dr. Brown

Thanks for publishing my letter to the editor in the March 2005 NEWSLETTER. I am impressed by the amount of space you gave David L. Brown, M.D., for a response and very impressed that your “Editorial Comment” after his response passed your own editorial review for accuracy. In fact, El Paso is training more nurse anesthetists, but the school is not based in El Paso. It is based in Fort Worth. They simply use the facilities left behind by the departed residency program in El Paso.

The points made in my letter were: 1) There is an apparent conflict of interest with the presence of American Hospital Association (AHA) representatives on the Accreditation Council for Graduate Medical Education (ACGME) Board of Directors; 2) there are few, if any, active program directors on the Residency Review Committee (RRC); 3) facilities abandoned by our discarded residency programs are being used to train more nurse anesthestists; and 4) the RRC did not communicate appropriately with the program directors (Association of Anesthesiology Program Directors/Society of Academic Anesthesiology Chairs [AAPD/SAAC]) or incorporate them into the process of designing a new curriculum. In fact Dr. Brown’s timeline did not include the most recent ACGME meeting (February 2005), where its unilateral proposals for curriculum change were solidly rejected by ACGME.

I believe my conclusion still holds. The RRC should (as opposed to “must”) attempt to utilize the skills and experience of current program directors in accomplishing what should be its mission of salvaging the training programs we have left.

Randall C. Cork, M.D., Ph.D.
Shreveport, Louisiana

Editor’s Note: While Dr. Cork is entitled to his opinion, I would beg to differ with several of his points. First and foremost, there are two active anesthesiology program directors as listed by ACGME on the RRC and one pediatric program director. There are six department chairs, all of whom run (or have run) residency programs, and they understand the impact of changes in curriculum on the academic department. While they might not be the designated program director, allowing another to mange the educational issues within the department and most likely further a junior person’s career, my contention is that they would have even more intimate knowledge of the impact of any change in the residency program on an anesthesiology department.

It is most interesting that there is a member of the RRC for Anesthesiology who is an associate dean for graduate medical education at his/her university. Dr. Brown’s timeline did not include the February decision because at the time he wrote the letter, the decision had not been made. A simple glance at the ASA NEWSLETTER “Information for Authors” informs the reader that the deadline for submission is a month before publication. Thus his response was submitted for publication on February 1, 2005.

While the communication may not have been effective from the RRC, it was not from a lack of trying, as Dr. Brown clearly delineated. Whether the decision was “unilateral” or not is often in the eye of the beholder. Remember that it took more than 30 years for the three-year anesthesiology curriculum to be accepted, although the first two programs to offer residencies in anesthesiology were three years beyond the intern year at the University of Wisconsin in 1927 and Mayo Clinic in 1928.

Finally ACGME oversees all of graduate medical education, of which anesthesiology is, unfortunately and numerically, a small part. AHA has, since the 1930s, been an advocate of nurse anesthesia. When the National Association of Nurse Anesthetists (the forerunner of the American Association of Nurse Anesthetists) was formed, AHA provided some assistance with the organizational process, drawing up bylaws and other such procedures.

Given that a considerable amount of graduate medical education takes place in the hospital setting, it makes sense that AHA has a role to play in ACGME. It has only four votes out of 27 on the Board of Directors. How much of a conflict of interest this is remains for the reader to determine. Quite simply I believe Dr. Cork’s conclusion that “we need to take steps to preserve the future of our profession, and we can’t do it by letting others abort our future professional offspring” is in error. As recent letters to the editor will assert, there is a perceived quality problem both with some American medical school graduates and some international medical school graduates who complete an anesthesiology residency training program.

It is the duty of the RRC to see that our professional offspring are quality physicians able to function as consultant specialists in anesthesiology — in my opinion, nothing more or less. The RRC membership is well chosen and positioned to do this. Having been a program director myself in a less-than-resource-rich setting, and having answered RRC concerns about that program, I feel comfortable that the RRC has the best interests of the specialty and our future at heart. The specifics of the four-year curriculum may need further debate and modification. In many ways, though, the ideas behind it, having a uniform clinical experience for all four years of training in the specialty, are sound.

— D.R.B.

Accreditation Where Accreditation Is Due: Reaction to Dr. Brown’s Letter

In his reply to the letter from Randall C. Cork, M.D., Ph.D., (March 2005), David L. Brown, M.D., indicates that the Accreditation Council for Graduate Medical Education (ACGME) has a continuum of accreditation length (one to five years) that provides a rough guide to program quality. In the absence of comparisons with other specialties, these data are difficult to interpret. Fortunately the ACGME Web site <www.acgme.org> allows one to obtain similar data for other fields. As displayed in the figure below, there are striking differences between anesthesiology (AN) and internal medicine (IM) or general surgery (GS). While a large majority of programs are “solid” or “mostly sound” in IM (70.6 percent) and GS (67 percent), a majority of programs in AN (58.3 percent) face significant challenges or worse. In IM and GS, the accreditation pattern follows a decreasing, stepwise progression, while in AN, accreditation lengths are almost evenly divided between the five alternatives. Finally, in IM and GS, a small minority of programs have only a one-year accreditation status, while one in seven programs faces this fate in AN. When thinking of reasons for such differences, at least four possibilities come to mind:

A majority of anesthesiology residency programs are deficient in their educational obligations. The recent challenges to academic anesthesiology have been well documented (e.g., faculty shortages, high chair turnover, financial difficulties, etc.) and may explain the poor educational performance of most programs.

The program requirements are at odds with the current practice environment. The program requirements have not been adjusted for numerous changes in surgical and clinical practice (e.g., on-pump to off-pump cardiac surgery, endovascular rather than surgical interventions, critical care staffing patterns, etc.).

The Residency Review Committee (RRC) for Anesthesiology has more rigorous standards than the RRCs for other specialties. While the members of the RRC for anesthesiology are undoubtedly individuals with a strong interest and dedication to graduate medical education, only three out of 10 members are presently departmental chairs or core program directors. One can wonder whether there is a division between educational expectations and the realities of departmental management.

The Conspiracy Theory. While most reject the thought that the RRC is on a mission to eliminate programs, it is unfortunate that an elitist viewpoint espousing that the specialty would be better off with “50 great programs” than with its current allotment is at times propagated by some academic leaders.

The divergence between the accreditation pattern of anesthesiology and that of other specialties is most certainly multifactorial, but it is nonetheless a reality, and this reality may affect the whole specialty. It is imperative that the reasons for the discrepancy be explored, understood and corrected.

Daniel M. Thys, M.D., President
Association of Anesthesiology Program Directors

Reply to Dr. Thys from Chair of the Residency Review Committee for Anesthesiology

In this issue of the ASA NEWSLETTER, Daniel M. Thys, M.D., comments on a letter published in the March 2005 NEWSLETTER. In it he comments on the length of accreditation decisions approved by our Residency Review Committee (RRC) for Anesthesiology, as well as reports on similar data for other specialties, within the larger context of oversight by the Accreditation Council for Graduate Medical Education (ACGME). In addition to his comments, he hypothesizes about the reasons for the differences found between the lengths of accreditation decisions for anesthesiology, internal medicine and general surgery RRCs. His hypotheses are interesting reading and made even more interesting by attributing and incorporating possible motives to the numbered hypotheses.

Having served on our specialty’s RRC for five years, I believe that residency programs have provided me more significant insight into how our specialty training programs really function than in any other role I have been involved in within our specialty. This includes all the visiting professor trips as well as the scientific and specialty leadership meetings I have attended.

In considering how my response might be most helpful to a wider understanding of our RRC, it seems best to reword Dr. Thys’ hypotheses into what seems to fit my understanding of the role the RRC/ACGME plays in our physician educational continuum while maintaining his hypothesis numbering plan for ease of comparison:

A majority of anesthesiology residencies have opportunities to improve their educational offerings. Dr. Thys’ examples of faculty shortages, high chair turnover, financial difficulties, etc., seem to fit with many of our reviewer experiences in understanding challenged programs.

The program requirements are at odds with future practice environments. The planning for program requirement change continues, and we hope to prevent the specialty from assuming an even more technical nature while supporting an educational continuum that promotes “thinking like a physician.”

The RRC for Anesthesiology has rigorous standards for review. It is not likely that our specialty has significantly more rigorous standards than other specialties since the ACGME monitoring committee reviews our committee’s work during each five-year cycle. If excessive rigor were an issue, it certainly would be brought to the committee’s attention. My sense is that hypotheses number 1 may have the most influence over the perceived “rigor.” Additionally, of our current eight RRC members, seven have been chairs, program directors or institutional graduate medical education officials in their respective departments and institutions; this is not the ratio quoted by Dr. Thys.

The Nonconspiracy Theory. Conspiracy is always an attractive hypothesis since it invokes images of a “selected few” manipulating the unsuspecting many. Please know that this fits much more attractively into a fiction section of our specialty than the nonfiction section. If there is a conspiracy under way, it is that the RRC for Anesthesiology often appropriately cites program weaknesses to help improve anesthesiology graduate medical education in institutions that are not providing sufficient resources to aid anesthesiology department programs. That fact fits into the nonfiction section of the specialty, and there are many examples of programs benefiting from this appropriate institutional pressure.

I hope my thoughts and rewrite of Dr. Thys’ hypotheses are helpful in making clearer the goals of the RRC for Anesthesiology and why our accreditation decision lengths are almost equally divided by years of accreditation.

David L. Brown, M.D., Chair
Residency Review Committee for Anesthesiology

Retiring and Dreading It

I am an anesthesiologist who is anticipating retirement this year and would like to express my opinion about where our specialty is headed. In a few words: We have met the enemy, and they are us! Too many practitioners have been very eager to turn over our work to nurse anesthetists who are now perceived by hospital administrators, surgeons and third-party payers as equivalent (or superior) to physician-administered anesthesia care. Physicians have become lazy and unwilling to see patients preoperatively and delegate that service to nurse practitioners, physician assistants and nurse anesthetists.

In my own practice, I have seen a giant step backward from viewing the anesthesiologist as a perioperative physician who is intimately involved in the preparation of the patient for surgery.

My current chairman now requires the patient to see the primary care doctor and other specialists instead of utilizing an anesthesiologist-directed approach to the preparation of the patient. I am sorry to see this state of affairs at the end of my career, and these situations have contributed to my decision to leave the profession. I love my work but feel that the perception of the anesthesiologist as consultant and colleague in the hospital has been diminished. Unfortunately, as I age, I will increasingly require anesthesia services to replace my aging joints, and I believe that I will find a competent, experienced nurse anesthetist and token physician to administer my anesthesia.

Patricia I. Carella, M.D.
Norton, Massachusetts