Doc’s Sabbatical No Child’s Play

I have just completed a sabbatical month with the department of pediatric anesthesia at the Cincinnati Children’s Hospital Medical Center. I was inspired to do so by the article “Providing Anesthesia for Pediatric Patients” from the March 2005 ASA NEWSLETTER, submitted by Alvin Hackle, M.D., and George A. Gregory, M.D.

My community hospital affirmed that our younger patients, especially neonates, had an increased risk of anesthesia-related morbidity and mortality. Both the American Academy of Pediatrics and the Society for Pediatric Anesthesia have published statements emphasizing the additional responsibility and special care needed for anesthetizing children. Our anesthesia division was given the task to fill this need.

Currently fellowship-trained anesthesiologists are at a premium. We have a 30-percent pediatric case load in our rural community hospital. We decided our best approach was to designate a “team” with “special clinical privileges” for our anesthesiologists and anesthetists to enhance our pediatric perioperative care.

The term “regionalization” used in the article is very relevant to our circumstances. I contacted Paul J. Samuels, M.D., Pediatric Anesthesia Education and Fellowship Director at Cincinnati Children’s Hospital Medical Center, and set up my sabbatical. Interestingly Dr. Samuels had been developing such a program, and I was pleased to be an early participant.

I began working in the operating room doing my own cases with supervision. I also had the opportunity to observe the flow and gained insight into what makes Cincinnati Children’s run “like a well-oiled machine.” In the end, my experience will be invaluable to me, my hospital and the children in our community. This kind of pediatric experience makes one realize that simple things can be done in one’s own practice to ensure good outcomes for noncritical situations. The level of cases may never be as complicated at my hospital as they are at Cincinnati Children’s; however, vigilance, respect for the airway and having a “team” that works well together on pediatric cases will improve the quality of anesthesia for infants in my community.

I encourage others to take the time out of the “real world” of private practice to expand your expertise and undertake a pediatric anesthesia sabbatical. Your practice and your pediatric community deserve it.

I give my respect to the pediatric anesthesia and surgical staff and thank you for making my sabbatical a rewarding endeavor.

Michael E. Vega, M.D.
Huntington, West Virginia

Hands Off Is Not a ‘Handoff’

I would like to respond to the letter from J. Antonio Aldrete, M.D. (April 2005 ASA NEWSLETTER), “Which Nonphysician Will We Give Our Jobs to Next?,” which criticized Committee Opinion Number 295 of the American College of Obstetricians and Gynecologists that supports management of labor epidural infusions by labor and delivery nursing staff.

Labor and delivery nursing’s role in management of labor epidural infusions within approved interdisciplinary policies is not “carte blanche” as claimed in the disapproval of this practice. Involvement using standardized patient-specific order sets for continuous epidural and patient-controlled epidural (PCEA) infusion pump programming by nursing staff (following epidural insertion and initiation by the anesthesiologist), side effect management and epidural catheter removal following delivery are safe and acceptable; with written protocols and education, this is a reliable and efficient system in many busy labor and delivery units.

Labor pain management centers on patient safety and satisfaction. Recent literature disproving outdated claims of greater cesarean section risk in laboring patients receiving epidural analgesia (or receiving it “too early”) create higher regard for labor epidural techniques. Current modalities such as combined-spinal epidural (CSE) and PCEA with ultradilute agents provide safe, effective labor pain management while preserving lower-extremity motor control, allowing patients to participate comfortably throughout delivery. Higher utilization of epidural analgesia enables general anesthesia to be avoided for cesarean section, a major cause of anesthesia morbidity and mortality in obstetrics.
Committee Opinion 295, like many practice guidelines, is a general recommendation, leaving specific practices and initiatives to the capabilities and resources of individual institutions. At ours, labor and delivery nurses are highly motivated to have this active role in managing labor pain and enjoy the autonomy afforded by our system that promotes collaboration, not competition with anesthesiologists.
While it’s true that not every laboring patient must have an epidural, every laboring patient should have optimal pain management available when desired. Working collaboratively and proactively with our obstetric, nursing and pharmacy colleagues, as anesthesiologists, we can help fulfill this goal.

Michael Block, M.D.
Hackensack, New Jersey

Private Practice Anything But When It Comes to Teaching and Learning

I read the June 2005 “From the Crow’s Nest” with great interest. I feel that I have a unique perspective to offer, as I am a graduate from the program where Dr. Bacon now works. However, my graduation did precede Dr. Bacon’s arrival. Although I realize the main theme of the article addressed the Medical Scientist Training Program, Dr. Bacon did make several remarks addressing private practice anesthesiology that I found very troubling.

I have nothing but the highest regard for my days of training at the residency program that we have in common. My training has served me well, and I remember my days there fondly. I was able to publish two papers while there as a resident and indeed received a resident research award during my training.
Upon my graduation I chose to enter the world of private practice. The reason that I am writing this letter is by no means because I consider my career choice to be “wasted” or a “disappointment.” I have been actively involved in teaching medical students and residents as well as being actively involved in hospital committees and with both our county and state medical societies. In my opinion, I did not feel that the thoughts that he shared with regard to private practice were the predominant opinion of the faculty during my training.

The divisiveness that Dr. Bacon expresses regarding the career choice of academic or private practice anesthesiology does not serve our specialty well.

Scott M. Kuhnert, M.D.
Lansing, Michigan

Reader Gives Editor 3rd Degree

I read with great interest your article in the June 2005 ASA NEWSLETTER. I fail to see the importance of producing a class of researchers with both M.D. and Ph.D. degrees.

While your description of three residents is anecdotally interesting, your personal biases affect your conclusions. The gratuitous description of the residents “rags to riches,” “privilege to private practice” and “staying in school” serves little purpose. Your judgment of resident number two is particularly ludicrous. The physician entered private practice, which was a “disappointment” to you. However, the function of residency programs is primarily to train practitioners. You state, “His potential and society’s investment in him seems wasted.” This is the ultimate absurdity. How many patients will he serve during his career? How many patients will he save during resuscitative efforts because of his skills? Do you think “just administering” anesthesia lets society down?

In 1933, when Dr. Waters wrote his quote, there were indeed very few practitioners of our specialty, and teachers were needed for the specialty to develop and prosper. Today we face vastly different problems.

M. Jack Frumin, M.D., said to me many years ago that the beautiful thing about anesthesia is that we can learn from each and every patient. All we need to be is inquisitive. Mentoring young residents is of greater value and less costly than earning another degree. Clinical academic departments are routinely “taxed” by deans’ funds to supply funds to basic science departments. Anesthesiologists interested in doing research can call upon basic scientists to collaborate with them.

We need not fear for the future of academic anesthesia nor our specialty.

Garry S. Sklar, M.D.
North Woodmere, New York

Ivory Tower Needs to Open Its Doors

An interesting “From the Crow’s Nest” (June 2005) and very touching in many ways. A thought, though, about the solution to the problem you propose. What happened to the “town and gown” societies of old? There was a time when the decision to pursue private practice did not preclude one from contributing to the education of the next generation of physicians. Unfortunately there has developed a schism between academics and private practice, and it is helping no one.

Academics are not sending residents out into the community for “private practice rotations,” for fear they will choose private practice over a career in academics. Rarely are such decisions made on the basis of one rotation, and rarely are such decisions made in the latter part of residency.
Private practice physicians are turning up their noses at academic time because it often does not enhance their practices. True, the “ivory tower” pronouncements are becoming more and more unrealistic in the “trenches,” but the only way to shape the focus is to have input from the beginning, as in a collaborative effort in the academic world.

There are many areas where academics are too far removed to have an ongoing relationship like a town and gown society, but visiting scholar programs could easily be developed. This would allow interested private practitioners to pay for a two- to six-week refresher where they would travel to an academic center and be a visiting scholar. They might do cases or observe cases, give and attend lectures and provide a perspective on what the private sector is doing. This could be worked into any of a number of continuing medical education scenarios and could become a cornerstone of the recertification process as opposed to taking a test.

These are merely ideas from a practitioner who was sad to have to make a choice between academics and private practice and would love the opportunity to be thought worthy to contribute, even though not on faculty.

Stephanie Jo Dyer, M.D.
Greenville, Mississippi

Early Labor and Epidurals: The Devil Is in the Details

The landmark study by Wong et al. (NEJM. 352:355-65, 2005) is vitally important to our specialty. Patients are excited that they can request analgesia early in labor without increasing their risk of cesarean-section. Surprisingly, Wong reported that neuraxial analgesia actually decreased labor by approximately 90 minutes!

Anesthesia physicians must be aware of the details of this study. Wong’s group did not study epidurals in early labor as reported in the June edition of the ASA NEWSLETTER and WebMD. The study group was given intrathecal fentanyl in early labor, and epidural analgesia with local anesthetic/opioid was initiated when the labor was transitioning to the active stage. The control group received parenteral opioid in early labor and a traditional epidural at 4-5 cm. dilation.

Tachyphylaxis with local anesthetics is well known. It is possible (perhaps likely) that giving an epidural with a bolus of local anesthetic followed by a dilute local anesthetic/opioid infusion in early labor may have very different results.

I have incorporated Dr. Wong’s concepts in my practice and have been very impressed with the results. Clinically this really seems to work! I would like to describe the technique in detail since a few changes are required to make Wong’s concepts applicable to a busy private practitioner. A lumbar puncture is performed at L3-4 with a fine atraumatic needle. Fentanyl (25 mcg) is administered. The needle is removed. An epidural catheter is then placed. One may wish to place this one interspace higher than the LP. After placement, the catheter is aspirated and a test dose is given. A dilute solution, such as 0.125-percent bupivacaine with 2 mcg/ml fentanyl, is then started at 10 ml/hr. No epidural loading dose is given. Note that local is not given intrathecally in this early labor technique. If the patient is at 4-6 cm when we are administering CSE, I still use intrathecal local (e.g., fentanyl 20mcg/bupivacaine 0.6mg). Although I prefer two-stage CSE, physicians who use the needle-through-needle method should also have favorable results with Wong’s concept.

However, anesthesia physicians who utilize a traditional epidural method with a bolus of local followed by an infusion should be wary. This is not what Wong studied. If one prefers a traditional epidural, it may be prudent to give it at the traditional time: 4-5 cm. As with most important experiments, Wong’s study suggests a number of other questions to investigate.

Richard K. Baumgarten, M.D.
Grosse Pointe Farms, Michigan

Scope of Practice Makes Perfect, and Setting the Record Straight

ASA and this NEWSLETTER have done an admirable job in maintaining an active voice and forum for anesthesiologists nationwide on the important issues facing our specialty. I would like to suggest that we could all do better in setting and advancing strategies for dealing with some of our most long-reaching challenges looking forward. Aside from our primary mission of vigilance, safety and quality in patient care, there are two issues that deserve a continued, heightened level of awareness: 1) “scope-of-practice” laws and legislation and 2) a push toward increasing and better utilization of emerging technologies that enable an anesthetic electronic medical record. On both of these counts, anesthesiologists are uniquely positioned to have a profoundly positive impact on the level of perioperative care delivered throughout this country.

Scope-of-practice concerns for physicians are emerging in every community and across all specialties. From dentists pushing to perform complex cosmetic procedures, to podiatrists encroaching “up the leg” into traditional orthopedic surgeon territory, to nurse practitioners and nurse anesthetists pushing through legislative fiat to achieve medical doctor status, there is a dangerous social movement in our midst. Often disguised as remedies for social or demographic economic woes, these nonphysicians are attempting to achieve through lawmakers what they could not (or would not) work to achieve through education and training.

This is bad for society and risky for patients. ASA should work to halt this trend.
Building on the June 2005 NEWSLETTER cover piece “Professional Liability—Making ‘Cents’ of Medical Malpractice Trends,” anesthesiologists need to apply the same perseverance used to achieve unprecedented gains in patient safety (and lower malpractice premiums) toward the advancement and utilization of electronic medical record technology. Only through means to capture all possible data points in the perioperative experience of patient care will our specialty be able to move to the next higher level of patient safety, improved practice guidelines and better patient outcomes.

Adam F. Dorin, M.D.
San Diego, California

Performance Measures for the Real World

I have been saying for years that I would love to have my performance be the basis of my compensation, and I would love to see others have the guts to match up. I am not talking about performance measures like maintenance of normothermia and timely administration of antibiotic prophylaxis, as Alexander A. Hannenberg, M.D., suggested in the July issue of the NEWSLETTER. I am talking about intraoperative hemodynamic variability, rapidity of wake-up and extubation at the conclusion of surgery, cost of anesthetic agents used, SpO₂ on room air and pain scores when the patient hits the recovery room and then, of course, 30-day and two-year morbidity and mortality and patient and surgeon satisfaction indices. Then we would see how fast the specialty develops performance standards and whether or not all the crazy things that I claim are better for patients — like regional anesthesia, avoiding muscle relaxants and use of spontaneous ventilation during GA and immediate extubation of postoperative hearts — really make a difference or not.

When asked why it took so long to abandon high-dose opioid anesthesia in the routine cardiovascular surgery patient at least 10, if not 15-20 years after its time was past, Ed Lowenstein answered that “slow changes in the practice of medicine have more to do with human nature and the culture of medicine rather than science” (Srinivasa N. Raja, M.D., personal communication). When people’s livelihoods are on the line, I would suspect that we would find the most effective and best-performing techniques PDQ (pretty darn quick), and clinicians won’t be so slow to abandon outmoded techniques and adopt newer, more effective ones.

Leo I. Stemp, M.D.
East Granby, Connecticut