W.T.G. Morton to Hit the (Northwest) Highway?

For the last 43 years, every time I wrote to ASA, I have wondered why our home office does not have an address that would be meaningful and representative of our specialty. Although e-mail has substituted most personal and professional correspondence, I still like to hand-write letters to friends, officials and colleagues. But when I write the street address “N. Northwest Highway,” it just does not seem inspiring.

So on three separate occasions I have proposed to different ASA officers to begin an initiative with the local government of Park Ridge, Illinois, to change the name of “N. Northwest Highway” to “William T.G. Morton Highway.” After all, he made a major medical contribution to the whole world, a campaign that all of us have continued as of today.

Neighbors and passersby will inquire, “Who was he? Why the change?” I can hardly think of anyone who would be more deserving — the address of our ASA will be written with gusto and pride as our street.

J. Antonio Aldrete, M.D., M.S.
Birmingham, Alabama

Editor’s Note: It seems that Northwest Highway in Park Ridge, which is U.S. Highway 14, has already been named for a famous American. According to the Ronald Reagan Library and Foundation, and as reported in the Chicago Sun-Times as recently as 2004, that road also has been named “Ronald Reagan Highway.” ASA is fortunate to have its building in such a visible and accessible location, but being situated on a major highway does limit the potential for customizing our address.

— D.R.B.

Points Well Taken

The series of special features on informed consent in the July 2006 ASA NEWSLETTER^1-4 made several points.

1. The informed consent question is not about patient safety. An informed consent document improves the legal outcome of the physician, not the medical outcome of the patient.

2. There is no dispute that the informed consent discussion between anesthesiologist and patient is essential. The issue is the best way to document the informed consent discussion.

3. To that end, a paragraph on the surgical consent form listing anesthesia risks is inadequate as it does not document the discussion between anesthesiologist and patient.

4. No sane person would witness an informed consent document if it meant confirming that the content of the discussion was appropriate and the patient understood everything. The witness only confirms that the signature on the document is the patient’s. The witness asks the patient two questions: What is your name? Is this your signature? Then the witness signs.

5. No informed consent discussion can be totally complete unless the patient is board-certified in anesthesiology. The form used to document the discussion may be appropriately abbreviated to the anesthetic plan, alternatives discussed, common complications, catastrophic risks and confirmation that all questions were answered. For bureaucratic reasons stated in the articles, this can be condensed to one page, large type.

Thank you for these thought-provoking articles.

Samuel Metz, M.D.
Portland, Oregon


References:
1. Domino KB, O’Leary CE. Should separate informed consent for anesthesia be adopted? ASA Newsl. 2006; 70(7):10.
2. Bierstein K. Informed consent and the Medicare interpretive guidelines. ASA Newsl. 2006; 70(7):13-14.
3. Sanford SR. Informed consent: The verdict is in. ASA Newsl. 2006; 70(7):15-16.
4. Cheney FW. A separate written consent document for anesthesia: What is the indication? ASA Newsl. 2006; 70(7):17-18.

Issue of Informed Consent During Labor Needs Some Work

I was interested in your piece (“From the Crow’s Nest”) in the July 2006 issue of the NEWSLETTER and the other essays on informed consent.

Conspicuously missing was any reference to emergency procedures. I realize that in serious trauma, consent is virtually implicit once the patient arrives in the E.R. However, in the field of obstetrics, the situation may not be so simple.

Both for emergency cesarean sections and for epidurals for labor, there can be problems. Seeking consent when the patient is clearly under considerable duress because of concern for the baby or because of intolerable pain may not be considered voluntary. It does not seem to make much sense to try to explain risks of neuraxial blocks to a patient under such circumstances. We do not have much access to patients prior to labor. Many of these patients anticipate that they will pull through without anything stronger than Lamaze and do not wish to hedge their bets by serious consideration of a pharmacological alternative.

During part of my career, I was director of anesthesia at the Kapiolani Hospital for Women and Children in Honolulu where 600-plus deliveries occur each month. I never really solved this conundrum to my satisfaction. However, now many years after my entry into private practice, the flood of attorneys emerging from the law schools makes the anesthesia pond seem ever more shark-infested.

Perhaps the NEWSLETTER can address this?

John W. Pearson, M.D.
Kailua, Hawaii

MHAUS Prez Sets Record Straight on MH Contributions

In the July issue of the ASA NEWSLETTER, an article highlighted the accomplishments of Paul D. Allen, M.D., Ph.D., who will deliver the FAER Honorary Research Lecture at the ASA Annual Meeting this year.

Dr. Allen’s contributions to anesthesiology, especially regarding the understanding of malignant hyperthermia, certainly merit this honor. The article indicates, however, that Dr. Allen and his group established the use of dantrolene in the treatment of malignant hyperthermia (MH) and the site of the genetic change most often associated with MH, namely the ryanodine receptor gene.

The persons responsible for the finding that dantrolene was of benefit in the treatment of MH were Keith Ellis, M.D., and Gaisford Harrison, M.D. (Ellis KO, Carpenter JF. Studies on the mechanism of action of dantrolene sodium. A skeletal muscle relaxant. Naunyn-Schmiedebergs Archives of Pharmacology. 1972; 275(1):83-94, and Harrison GG. Control of the malignant hyperpyrexic syndrome in MHS swine by dantrolene sodium. Br J Anaesth.1975; 81:626-629).

It was David MacLennan’s group who demonstrated the relation between MH and mutations in the ryanodine receptor gene in 1990 (MacLennan DH, Duff C, Zorzato F, Fujii J, Phillips M, Korneluk RG, Frodis W, Britt BA, Worton RG. Ryanodine receptor gene is a candidate for predisposition to malignant hyperthermia. Nature. 1990; 343(6258):55961).

Henry Rosenberg, M.D., President
Malignant Hyperthermia Association of the United States (MHAUS)

Editor’s Note: We thank Dr. Rosenberg for “setting the record straight” and apologize for any inconvenience the error may have caused.

— D.R.B.

In-Flight Emergency Kit Peppered With Anesthesiology’s Influence

A comment on “If There Is a Doctor on the Plane, Please Notify One of the Flight Attendants” from the August 2006 ASA NEWSLETTER: In the early 1980s, the ASA Committee on In-Flight Emergency Medical Care — which I chaired and of which the late M.T. “Pepper” Jenkins, M.D., along with others, was a member — had the opportunity to make recommendations to the federal government on the equipment and medications that should be required on commercial air flights.

That effort began because Pepper had a similar experience to that of the author, Richard O’Leary, Jr., M.D., and I had hoped to get the airlines to identify physicians, especially anesthesiologists, aboard flights prior to departure in order to respond quickly to in-flight emergencies. The effort to identify physicians aboard flights never got any attention, but with the help of former ASA counsel Michael Scott, Esq., ASA was able to make recommendations, which I believe were published in the Federal Register as to the equipment and drugs that should be available to a physician on board.

Since Dr. O’Leary states that he was supplied an “amazingly well-stocked medication kit,” I would like to think that was a result of ASA’s efforts many years ago, and, on a personal note, I hope Pepper has a smile on his face in heaven. An additional comment: ASA’s archive of the past history of its efforts seems to be lacking or possibly is never queried when important issues arise. In fact, Pepper and many others were visionaries when it came to critical arenas in which we should be involved as anesthesiologists.

Another example: the use of nitrous oxide by physicians in emergency rooms.

Wilson C. Wilhite, Jr., M.D.
1994 ASA President
Daphne, Alabama

Why Can’t ASA, AMA Members Participate in Lethal Injection?

I was interested to read the recent “Message From the President: Observations Regarding Lethal Injection” (August 2006). I commend Orin F. Guidry, M.D., for openly discussing this controversial subject. He clearly points out that in order to facilitate the administration of a lethal injection in a humane manner, proper drug doses, appropriate administration and clinical monitoring are essential. However, Dr. Guidry notes that ASA and the American Medical Association (AMA) have policies against physician participation in such activities. As a member of both organizations, I can state that I did not vote for this position nor was I asked about my opinion. In fact, I am against it.

Dr. Guidry’s article is preceded by an editor’s note stating that what follows is not about the morality of capital punishment. However, if an anesthesiologist is needed to provide for proper and humane lethal injection, by not approving of such participation, ASA and AMA are in effect impeding the performance of such injections. Accordingly, these societies appear to be against them.

The proper administration of a lethal injection clearly calls for the services of an anesthesiologist. I agree that this is not an assignment that many would want. However, if a volunteer is found, why should that individual be inhibited in any way by medical society rules?

Mitchel B. Sosis, M.S., M.D., Ph.D.
Lafayette Hill, Pennsylvania

Our Nonparticipant Status Has Lethal Connection

I have to respond to Dr. Guidry’s explanation regarding ASA’s decision to endorse the American Medical Association’s (AMA’s) position on lethal injections. I am troubled because I find AMA’s position on lethal injection to be a political statement and not a medical or ethical statement. AMA policy states that:

“A physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution.”

All parties on either side of the issue can agree that legalized execution is not the practice of medicine, and, in fact, it has been relegated to para-medical personnel such as EMTs to carry out the administration of this procedure. It can logically follow that if it is not the practice of medicine and is a legally sanctioned procedure, why should AMA or ASA have an opinion on whether physicians participate in lethal injection? Because of our higher status as physicians, the statement tells us there are certain activities that we should not take part in. The above statement reeks of elitism that characterized medicine 100 years ago when physicians were held up to be of a higher moral and social status than the common man. Lethal injection is legal, and the majority of the public believes it is an ethical procedure. The only conclusion that follows is that AMA and implicitly ASA are against lethal injection and are using their political power to interfere in the process. What would be the firestorm if I substituted the word “abortion” or “stem cell transplantation” for lethal injection? Many physicians have participated in hastening the end of life when the patient is suffering a horrible death. Is this beneath us as physicians “dedicated to preserving life?”

I can also make a rational argument that physicians should be ethically compelled to participate in lethal injection. If indeed there is a question as to whether patients are awake during this procedure and patients are going to be executed nonetheless, who better to ensure proper I.V. access, unconsciousness etc.?

ASA has decided to endorse AMA’s position on lethal injection against physician involvement. Yet I find Dr. Guidry’s overview of the controversy very thorough and well thought out. Dr. Guidry’s conclusion is that we as anesthesiologists should stay clear of the controversy. I couldn’t agree more, and I only wish ASA and AMA had done the same.

Amir Tulchinsky, M.D.
West Hartford, Connecticut

Painless Death Penalty Impossible to Execute

Only an attorney or judge could condemn a person to death, assign them a date and carry out the whole gruesome process and not consider that “cruel and unusual” and then worry whether the potassium burns on injection. Our patients sometimes feel burning from propofol or rocuronium (even when they are supposed to be asleep), and they haven’t been convicted of a capital crime.

I am opposed to the death penalty (even for Hitler!), but if we are going to kill a chicken (I’m also a vegetarian) or a human, how do we know our method is humane? Has anyone asked the executionee after the event? Does the condemned feel pain from a bullet or an electric shock or at the end of a rope? Can the victim of a guillotine observe his own body for a few seconds before cerebral function stops?

If I supported capital punishment, my response would be “Who cares? In a few seconds, they’ll be dead with no memory of the insult.”

Pardon me while I try to figure out how many angels can dance on the head of a pin.

Jeffrey S. Lee, M.D.
Los Angeles, California

Editor’s Note: Many thanks to all the ASA members who wrote and expressed an opinion about capital punishment. There is simply insufficient space to publish all the letters. These three represent the opinions of the vast majority of those writing in. We will not publish any additional letters on this topic.

— D.R.B.