Offended Anesthesiologist on the Defensive
read Dr. Bacon’s February 2007 “From the
Crow’s Nest” in regard to the decision of
anesthesiologists not to anesthetize Michael E. DeBakey,
M.D. I am in agreement with Dr. Bacon.
All of us anesthesiologists have been in similar situations.
In each case, the ethics of the situation and the patient’s
wishes should have been paramount. Nevertheless, overly
aggressive surgeons wish to proceed by finding some
family who is willing to sign the consent.
For reasons that are beyond comprehension, the surgeon
wishes to proceed at all costs in such cases without
any regard for the patient’s rights, wishes or
the medical consequences. These episodes are widespread
in American hospitals.
The anesthesiologists, when lacking the surgeon’s
support, then have to resort to itemizing the multiple
medical reasons as additional justification for why
such surgical undertakings are foolhardy. Why are the
ethics of the situation not enough?
Texts on surgical ethics never discuss such situations
and ignore their existence. Dr. Bacon should be encouraged
to open a dialog about this matter with the American
College of Surgeons. Our surgical colleagues should
be at least as well versed in the ethics of these situations
as we are.
Why is it that we are always placed on the defensive
for holding the high moral ground? Why are we forced
to provide additional medical justification for our
position?
Lee A. Balaklaw, M.D.
Louisa, Kentucky
Editorial
Underscores Anesthesiologists’ Real Roles
found your “Shadow
Warriors” (February 2007)
fascinating and thought-provoking but must disagree
with your conclusions.
Once Dr. DeBakey was unconscious, his wife was legally
authorized to decide on his treatment. Assured by a
competent surgeon that there was a chance (even though
slim) to save her husband, any loving wife would accept
surgery. The do-not-resuscitate orders signed by a patient
often impose a great emotional burden on the next of
kin. The decision to operate rested with the wife, not
with some ethics committee. The hospital director’s
opposition to another anesthetist was both petty and
illegal.
Your analogy to the Jehovah’s Witnesses is misleading:
“Witnesses” not only refuse transfusions
but their families almost always oppose blood administration.
Once the next of kin and the surgeon agree to proceed
with the surgery, an anesthesiologist is not qualified
to interfere with the decision. Many dissecting thoracic
aneurysms have been successfully operated. The first
anesthetist may have felt incompetent to provide this
challenging anesthesia or may have been more honest
to say so to the surgeon and his colleague during the
procedure.
It is not the anesthetist’s role to decide on
the surgery. His duty is to offer his (not unconsiderable)
skills to help the surgeon perform the procedure and
keep the patient alive. John Snow, to my knowledge,
never refused to administer an anesthetic to a sick
patient. In fact, he mentioned several times that no
patient was too sick to undergo a skillful
anesthesia. And that skill won him the esteem
of his surgical colleagues and the London public.
Sorry to disagree, Doug. Again, I immensely enjoy reading
your editorial.
Ray J. Defalque, M.D., M.S.
Birmingham, Alabama
Victimizing
the Victim
he “From
the Crow’s Nest” editorial published in
February 2007 explores in a perceptive
manner the clinical and ethical issues surrounding
the perioperative decisions concerning the aortic
aneurysm surgery of Michael DeBakey, M.D., albeit
based on a solitary news report by Lawrence Altman,
M.D.1-2
However, this sensitivity abruptly disappears in the
last paragraph when Dr. Bacon accuses the anesthesiologists
of doing a “disservice to both the profession
and themselves” by not speaking publicly about
this patient care episode. To me this is victimizing
the “victim.” Not only did the anesthesiologists
not have an obligation to speak to the media, but
such an interaction may have been counter-productive.
Although Dr. DeBakey reportedly “permitted his
doctors to talk,” there are HIPAA-related issues
of patient confidentiality. Second, the Methodist
Hospital anesthesiology group may have been appropriately
concerned about its ability to get its side of the
story to the public in an unbiased fashion.
Many who deal with the press, both print and media,
have witnessed on a personal basis that a long interview
is often reduced to a 15-second sound bite or a one-sentence
quote taken out of context. The veracity and ethics
of the press have come under such scrutiny that even
the New York Times itself, Dr. Altman’s
own newspaper, regularly publishes a column titled
the “Public Editor” by Bryon Calame (Public
Editor) to discuss issues of biased, incorrect or
incomplete reporting of events in the Times.
As a matter of fact, in a November 5, 2006, column
(unrelated to the Debakey story) he states:
Seeking comment from those written about, especially
when they are put in an unfavorable light, is a
particularly important aspect of fair coverage.
It helps ensure that readers get the most complete
and accurate view possible of a newsworthy development.
Unfortunately, The Times has had too many cases
recently where subjects weren’t given a chance
to comment, or the attempt to reach them was insufficient.3
To continue the use of the military metaphor employed
by Dr. Bacon in the editorial piece: Not all
battles are won by a frontal attack!
Paul G. Barash, M.D.
Orange, Connecticut
References:
1. Bacon DR. The
shadow warriors. ASA Newsl.
2007; 71(2):1-3.
2. Altman LK. The man on the table was 97, but he
devised the surgery. New York Times. December
25, 2006:A1, A14.
3. Calame B. The Public Editor; Listening to both
sides in the pursuit of fairness. New York Times.
November 5, 2006:Section 4:12.
‘Shadow
Warriors’ Editorial Highlights Ethical Dilemma
 r.
Bacon, in your “DeBakey”
editorial (February 2007), you handled
a very difficult and sensitive subject with great skill,
balance, compassion and consummate tact, while pointing
out the professional rights and privileges of all members
of the team and the patient. These ethical and moral
dilemmas with which we are called upon to grapple often
defy a clear resolution.
I just wanted you to know how much I admire your astute
and thoughtful analysis.
Best personal regards.
Clyde W. Jones, M.D.
San Diego, California
World Awaits Neuraxial Blockade
Infection Recommendations
 eading
of the article about complications related to infections
after neuraxial blockade in obstetrics, written
by Samuel C. Hughes, M.D., was an intellectual pleasure.1
It was really reassuring to have this subject being
debated after many decades of generalized neglect. Regarding
this important adverse event, the recommendations that
will be discussed by the task force1
are really very important worldwide, because many other
countries look up to the ASA for help in guiding improvements
in their own standards.
As it has been pointed out by Auroy et al., the control
of rare events requires analysis of both outcomes and
process of care.2 We definitively need to improve the
care we have with the many steps related to neuraxial
anesthesia, especially in countries where equipment
for regional anesthesia is unfortunately still being
reprocessed. These ASA recommendations or practice guidelines
are eagerly awaited by many of us outside the United
States.
Rogerio L.R. Videira, M.D.
Sao Paulo, Brazil
References:
1. Hughes SC. Neuraxial
blockade in obstetrics and complications related to
infection: Can we lower the risk?
ASA Newsl. 2007; 71(2):7-8,21.
2. Auroy Y, Benhamou D, Amaberti R. Risk assessment
and control require analysis of both outcomes and process
of care. Anesthesiology. 2004; 104:815-817.
Shield
Your Eyes: February NEWSLETTER Cover Potential
Health Hazard
am confused.
Why are protective eyewear and gowns recommended/required
for central line insertion and operative procedures,
whereas the cover photo of the February
2007 ASA NEWSLETTER clearly
shows an obstetric anesthesiologist performing an epidural
without eyewear protection or utilizing a sterile gown?
Likewise, the photo on page 13 of that same issue reveals
the lack of protective eyewear by all of the members
of the obstetric operative team.
Is protective eyewear for providers appropriate, or
is it not? In our state, the State Board of Health requires
eyewear protection, including side shields, or similar
protection, for all persons in the operating rooms.
Is there any reason to believe that potential fluid
or blood splatter to a physician’s eyes from an
HIV or hepatitis-positive patient is any less serious
for a physician in the obstetric area as it is in the
operating room area?
Epidural infections are indeed devastating complications.
If gowns and gloves are effective in decreasing central
line infections
(same issue, page 8),
why are those protective elements not effective in dimishing
infections during placement of epidurals? Similar to
central line-related sepsis, neuraxial infection can
be easily missed and/or under-reported.
What is appropriate? Is there really a difference between
the operating room, the intensive care unit and an operative
obstetric suite concerning appropriate sterile technique?
I would recommend that the appropriate ASA committee(s)
address this issue.
Steven R. Young, M.D.
Indianapolis, Indiana
‘A New Responsibility’
Meets Age-Old Wisdom
expect this letter to the editor to be trashed under
one of the following categories: Dr. Angiulo doesn’t
know about which he writes, and/or Dr. Angiulo is not
making a politically correct statement, and/or Dr. Angiulo
doesn’t know the facts and/or law of the case
about which our past president is writing (March
2007 “Administrative Update: A New Responsibility”).
I have been a practicing physician for 34 years, an
attorney and member of the Arizona Bar for 21 years,
a pro tem or full-time judge for 11 years and a grandchild
for 59 years, though my grandparents have been deceased.
My heritage has taught me that unless I could say something
good about a person, say nothing at all. How is this
different from a request for information about a colleague
in practice? Tell the truth or, absent a legal requirement
to respond, say nothing at all.
Treat a request for information as if it will be used
to give you the truth about a physician who is about
to perform his/her services on you or a close family
member. Do we really need courts to tell us these basic,
common sense principles? These are the principles that
my grandmothers passed on to me long before they passed
away.
Thank you for consideration of my letter to the editor.
James P. Angiulo, M.D., J.D.
Tucson, Arizona
A Wife’s Response to Dr.
Bacon’s ‘Blue and Gold Stars’
was moved to tears as I read the
March “From the Crow’s
Nest” in the ASA NEWSLETTER.
In response, after collecting my composure, I say a
passionate “thank you” to Dr. Bacon.
I am a Blue Star wife! My husband, Col. William W. Pond,
M.D., anesthesiologist, is currently deployed to Baghdad
in support of Iraqi Freedom for the fourth time. In
this deployment, he serves as Commander to the 447th
EMEDS and is ranking physician in Baghdad. In past deployments,
he served as a member of the Critical Care Air Transport
(CCAT) team, an airborne rescue team. I am proud of
my husband’s service to our country. I miss him
greatly.
I pass the time keeping busy as a diversion. I just
returned from Cambodia serving as a member of Operation
Smile, a humanitarian medical team serving children
in third-world countries that provide free surgical
repair of cleft lips and palates. This was my 12th mission
overseas, and I can truly state that nowhere in the
world does better health care exist than in our great
nation. I deeply appreciate members in our medical field
who sacrifice long hours to those in need of treatment
both here and abroad.
Our troops deserve the same respect and medical care.
And they need good doctors. I commend you for your support
of their endeavors, faced with danger and adversity,
as they provide care to our wounded husbands, sons and
daughters. I can assure you that no one knows what it
is like to stay back home without their loved one unless
they live it, because despite the many diversions that
I place in my path in the course of the day, I come
home to an empty, still house with the cold reality
that my husband is in harm’s way. He is away from
his practice and our family protecting others, defending
the freedoms that you and I enjoy.
Many in our country at present do not support our troops
in service, citing various political reasons. And hence,
sadly, where once was patriotism now lies contempt.
Yes, save a place for them, and remember to thank them
for their service to our country when they return home!
They, indeed, have honored the “flags of our fathers.”
Thank you for defending their honor.
Camille M. Pond
Fort Wayne, Indiana
The
views and opinions expressed in the “Letters
to the Editor” are those of the authors and
do not necessarily reflect the views of ASA or the
NEWSLETTER Editorial Board. Letters submitted for
consideration should not exceed 300 words in length.
The Editor has the authority to accept or reject any
letter submitted for publication. Personal correspondence
to the Editor by letter or e-mail must be clearly
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