Dr. Lema’s D-Day Analogy Off the Mark

am writing in response to the February 2006 “Administrative Update” column written by Mark J. Lema, M.D., Ph.D.

Dr. Lema compares the current ASA membership roster, some 40,000 members, to the soldiers of the United States Army who landed at Omaha Beach on D-Day.

At first I dismissed this as another example of the hyperbole one expects to find on the editorial pages of specialty newsletters. In this case, however, the analogy exceeds the limits of decency.

Dr. Lema sets forth a number of ongoing issues facing the ASA membership, most of them pecuniary in nature. How dare he compare this to the D-Day mission faced by our military. The dangers they faced and the gravity of their mission has no parallel, not even in military annals. Dr. Lema should visit Pointe-du-Hoc and then the American Cemetery nearby that overlooks the beachhead. More than 9,000 American soldiers, most of them teenagers, are buried there. He should enter the hallowed ground of the chapel at Colleville-sur-Mer and then the Caen Memorial.

After a tour of those sites, Dr. Lema would be well-advised to return to his desk and compose an apology to the memory he desecrated with his silly article.

Mark H. Stein, M.D.
New Brunswick, New Jersey

Dr. Lema Responds

ear Dr. Stein:

While I appreciate your comments and respect your views, my analogy is both sound and does not desecrate the memory of those who fought in battle. There are many analogies between warfare and business, including Sun Tzu’s Art of War being required reading for M.B.A. students. Our constituents have ranked socioeconomic issues as their number-one priority. Thus discussion of these issues by the leadership is of paramount importance to the membership.

I encourage you reread the “Administrative Update” for the intended message it conveys — that each of us needs to actively advance our practice and not rely on someone else to do it.

Finally, it was my visit to the Duxford Air Museum and the American Cemetery that inspired me to write this editorial. I guess we just see things differently on this issue.

Mark J. Lema, M.D., Ph.D., ASA President-Elect
East Amherst, New York

Reader Looks for Guidance on Hot Issue

false alarm last week has prompted us to review the protocol for evacuating our ambulatory surgical center during a fire (or other disaster). How timely in light of the content of the episode of “Grey’s Anatomy” referred to in the letter from ASA President Orin F. Guidry, M.D., to the show’s producer <www.ASAhq.org/news/news020606.htm>. The safety and security officer who responded to our false alarm was astounded that all of our personnel were not evacuating. It was clear he had no clue that you could not just leave an anesthetized patient behind because there might be a fire. Maybe he has been watching too much television.
 
The fire code for health care facilities is very specific, including decibel level of the alarms, placement of sensors near sterilizers and other equipment and who has the authority to shut off the alarm in the event of a false alarm. They are very serious about timely evacuation. Are there any standards for how to deal with evacuating those patients who are anesthetized or still recovering from anesthesia? I would assume that as the head of the anesthesia care team, it would be my responsibility to care for the safety of my patients and their families as well as my personnel. Obviously this would entail a great deal of responsibility and potentially exceedingly difficult decisions. As Mark A. Warner, M.D., would say, “who better to do this than an anesthesiologist!” The idea that when the bell rings everyone leaves and returns only after someone gives the all clear is unacceptable. 

ASA should have a standard for this. It would not be the first time unsafe regulations were forced upon us, like locking up life-saving medications. Please enlighten me if such guidelines exist. If not, perhaps we should work on some!

Glenn A. Fromme, M.D.
Medical Director, St. John’s Surgery Center
Springfield, Missourik

Sedation Debate Goes ‘Round and ‘Round

any have purported that for sedation to be safely practiced, someone formally trained in anesthesia must be providing the related care. Sedation by nonanesthesiologists, however, has been a long-standing practice. Many reports totaling more than 200,000 patients document that nonanesthesiologists can and do provide safe and effective sedation with propofol. The absence of any reported deaths (or even tracheal intubations) in peer-reviewed journals concerning patients sedated with propofol by nonanesthesiologists stands in dramatic contrast to the early experience with midazolam.

Propofol has some common and unique attributes and disadvantages. All drugs typically do. We all know that patients can suffer significant respiratory depression and associated negative outcomes after receiving fentanyl and midazolam just as well.

It is intuitive and largely recognized, even by nonanesthesiologists, that deep sedation requires a greater degree of care than moderate sedation and that the use of propofol should be consistent with standards of deep sedation care. This includes a trained individual dedicated solely to monitoring the patient. This is where the petition to the Food and Drug Administration that was submitted by three gastroenterological societies was wrong. Their petition “bundled” into their request both the notion that propofol could be used nonanesthesia-trained practitioners and that there was no need for a trained individual dedicated solely to monitoring the patient. While I agree with the first request (under proper conditions of education, training, competency and quality improvement), I disagree with the second, as do even some of the gastroenterological publications on this issue. It is how a drug is used, not which drug is used, that largely determines outcome.

The reality of sedation practice is that there are far more sedations required than could ever be staffed by anesthesia-trained individuals. And it is my belief that it is time for all parties concerned, including patients, to form a process whereby we can all work together toward resolving controversies and defining how to best guide all care that requires sedation. It seems that it is time for a national board and/or certifying organization to be formed and that this organization is empowered and charged with the responsibility to standardize, direct and oversee sedation in health care for all practitioners and patients.

Peter L. Bailey, M.D.
Rochester, New York

Doc Waves Yellow Flag at G.I. Industry

fter reading the erudite and provocative articles written by John P. Abenstein, M.D. (December 2005 and February 2006) and Keith M. McLendon, M.D. (February 2006) concerning the use of propofol by our friends in the G.I. industry, it is with great trepidation that I offer this Humble Hoosier advice to the latter (with apologies to the television commercial folk):

“Closed course, professional driver. Do not attempt this at home.”

Kenneth R. DeVoe, M.D.
Greenwood, Indiana

Frodo, Dude, Was a Liberal

our discussion of the import of our Society and those who serve it as “willing to make the sacrifices necessary to advance the specialty” (February 2006 “From the Crow’s Nest”) reminded me of a distinction I find between ASA and some other physician groups: the scientific society versus the guild.

The distinction is found in the essence of each association’s raison d’etre. Our Society exists to advance the science and the practice of anesthesiology. Several other groups exist solely to protect the economic welfare of their memberships.

While ASA obviously is a strong force in Washington and in the various states in the effort to make sure our members are appropriately compensated, that very important work surely does not comprise more than 25 percent of the activities of the Society’s officers. Rather I think the majority of the work they do is that to which you alluded: creating bridges to other organizations, creating practice parameters and promoting safety and the appropriate environment for sustained research.

On the other hand, physician organizations abound that work to promote only the economic welfare of their members, to make certain that the status quo is maintained. No real boundaries of science are challenged, and no impetus exists to change the way they practice other than to improve income. They are not much different from the medieval guildhalls, the chandlers and the cobblers.

ASA, on the other hand, is very much a liberal organization, in the nonpolitical sense that a “liberal” approach is one that favors reform and is open to new ideas. ASA is aimed squarely at change — at improvements in practice techniques, in safety, in accountability and in patient outcomes.

So, thanks to you (and your sons) for making me think of all this again: the liberals, the conservatives, the hobbits and the heroes.

Like Gandalf, heroic or not, it is good to be both gray-haired and “liberal!”

Douglas G. Merrill, M.D.
Seattle, Washington

Hobbits and Wizards and Bears, Oh My!

forced myself to wade through two pages of questionable Tolkien similes (February 2006 “From the Crow’s Nest”) to just see where you were going. Bacon, grow up! The Lord of the Rings is fantasy. It is indeed unfortunate that you analogize pretend stuff written for children with our specialty. Then again it is not surprising, for in that very same issue, we also learned that, thank heaven, the bears are back (Doctors Day 2006) to help us celebrate. Yesiree, “Doctors Care!” Not only is that sentence the ultimate banal cliche, it’s poor English. “Doctors care!” I can hear my fifth grade teacher exclaim, “care about what?”

Let’s go the whole way: Doktrz Kar. If you can’t lick ’em, join ’em!

Steven S. Kron, M.D.
Avon, Connecticut

In Praise of Disruptive Anesthesiologists

In response to the February 2006 “Practice Management” column describing disruptive physicians, I would like to go on record as praising constructive disruption. The day we become “nondisruptive” is the day our specialty dies.

The medical specialty of anesthesiology is inherently disruptive. This is not to say that we have a propensity toward losing our tempers and lashing out at our colleagues inappropriately. Rather we are disruptive in the sense of “disruptive technology.” Unlike the physicians who require our services, we do not generally (outside of pain management) intervene positively to improve our patients’ lives directly. Instead we disrupt the processes of pain, hypotension, hypoxia and death that would otherwise afflict our patients during procedures in our absence. We are seen as disruptive physicians when we say “no.” When we identify patients who are unready to survive a procedure due to inadequate medical work-up, we disrupt the operating room schedule and the surgeon’s income (and primate alpha status). When we state that a patient with sleep apnea needs to be admitted overnight postop, we disrupt the patient’s plans for “in and out” surgery. When we aver that our sickest patients deserve evidence-based transfer to a facility with a higher level of care, we are seen as obstructionistic.

Every day, anesthesiologists around the world are subjected to verbal abuse, complaints to administration and/or career-ending reprimands for doing our jobs as we understand them: to act as “disruptive” perioperative physician consultants whose key role is to ensure optimal patient care. For our specialty to survive and flourish, we need to continue to act as the crucial brakes on the ever-accelerating surgical vehicle. I plan to remain a constructively “disruptive” perioperative physician in the interest of both patient safety and the rational practice of my beloved specialty.

Robert C. Jones, M.D.
Edgewater, Maryland