Awareness Article Light on Science
 t
was extremely enlightening to read patients’ accounts
of anesthesia awareness (AA) (April
2007 ASA NEWSLETTER). Certainly
this article highlighted the suffering that has occurred
in some cases that many anesthesiologists have regrettably
dismissed as mild forms of awareness. However, it is
important to note some of the outside factors that have
led to this problem.
First, surgeons, PACU nurses and O.R. administrators
are constantly (over-)promoting rapid wake-up and discharge
for all patients. This demand surely causes anesthesiologists,
in the aggregate, to use “lighter” anesthesia,
as does the requirement for rapid O.R. turnover. Is
it unexpected that the prevalence of “light”
anesthesia has led to an increased incidence of awareness?
Second, while narcotics control cannot be compromised,
pharmacists who make it inconvenient to sign out midazolam,
ketamine and narcotics, especially in trauma and obstetrics,
will indeed reduce appropriate usage of these items,
with AA (and postoperative pain) rates rising.
Third, it is unproved that brain function monitoring,
as used today, reduces AA. In fact it may increase
AA, as practitioners attempt to keep indices just below
the magic number. Brain function monitors are just as
likely used to keep the patient “light”
enough rather than “deep” enough.
High patient volume, rapid turnovers and early discharges
may be necessary for the bottom line, but they also
may lead, statistically, to more AA.
Howard Schranz, M.D.
New York, New York
Nothing
Sells Like Fear
o one is arguing that awareness under anesthesia is
a terrible yet rare event. What upsets me is the way
some corporations get us to buy their product.
Fear-based purchasing instead of scientific-based
evaluation and implementation is good for the pocket
book but maybe not for the patient. Solid studies
about certain claims are few. What is definitive is
the media blitz from news sources and the companies.
Fear-based victimology sells well in all parts of
life, and it sizzles in the media. Give me and my
fellow physicians good old-fashion science.
If our octogenarians are dying off because of the
“Neurotoxicity of Anesthetic Drug Products,”
then let’s see some data. What is needed is
some vigilance on our part and some money spent on
research instead of commercials and honorarimercials
(honoraria-based wisdom).
Kyle M. Jones M.D.
Huntsville, Alabama
Disappointing
Public Relations
nfortunately, it seemed as if the Malignant Hyperthermia
Association of the United States (MHAUS) and ASA’s
recent joint public relations promotion that ASA members
received [in the January ASA envelope mailing] was
lifted from the typical Hollywood medical thriller.
You know the script: In addition to performing dramatic
surgery, the surgeon must direct an incompetent anesthesiologist
to rescue a patient from a medical disaster.
In the MHAUS/ASA promotion that ASA members received,
a smiling father holds his happy young son and states,
“How quick thinking saved my son’s life.”
The problem? Just below the dad’s thankful statement,
MHAUS and ASA state, “His surgery team recognized
the signs of Malignant Hyperthermia
before it was too late.”
Say it ain’t so! The surgical team recognized
the signs of MH, not the anesthesia team!
If it’s true that the surgical team made the
MH diagnosis, then it’s a sad commentary on
the knowledge and vigilance of the anesthesia team.
If it’s false, and the anesthesia team made
the MH diagnosis, then it’s a sad commentary
regarding two fine national organizations’ ability
to promote the importance and skill of anesthesiologists
to the public and those who reimburse our services.
Richard Strunin, M.D.
Santa Rosa, California
MHAUS
Responds
e wish to thank Dr. Strunin for his comments regarding
our recent mailing where we intend to give a “face”
to the potentially fatal problem of malignant hyperthermia.
However, I am afraid that Dr. Strunin misinterprets
our statement regarding recognition of MH by the “surgical
team” as a slur upon the anesthesia team. The
primary aim of MHAUS is to educate those who are likely
to be involved in the diagnosis, treatment and management
of MH crisis and the MH patient. Our message has been
that the recognition and treatment of MH entails the
efforts of everyone involved in the patient’s
care from the O.R. secretary, to the transport aides
to the O.R. nurses, anesthesiologists and surgeons and
many other individuals. That is what is meant by the
“surgical team.”
This message is consistent with modern concepts of patient
safety that emphasizes multispecialty team training
in response to emergencies. Some examples include “code
teams,” rapid response teams and team training
for obstetric emergencies.1
We will give consideration, however, to expressing our
message using terminology that is less apt to be perceived
as a specialty-specific label.
Henry Rosenberg, M.D.
President, MHAUS
Livingston, New Jersey
References:
1. Murray D, Enarson C. Communication and Teamwork.
Essential to Learn but Difficult to Measure. Anesthesiology.
2007;106:895-896.
Biggest
Loser in ASA/AANA Fight Is Patient
 r.
Bacon, I just wanted to comment on your recent
editorial (May 2007). You are right
that until both ASA and AANA have leadership that brings
the two groups together to provide the best anesthesia
care possible, then no one will be able to work together.
The first time I worked with a CRNA was when I worked
at Erie County Medical Center as an attending. There
were two young CRNA women who, every time I was the
attending on the case, if I did anything to the record
besides sign it, I kid you not, they tore the record
up, totally redid it, and again asked me to sign it.
The next time I worked with CRNAs was when I was at
the Orlando VA as the Chief of Anesthesia, the Chief
of Ambulatory Surgery and the Chief of the Pain Clinic.
I hired an older CRNA who was in her late 50s. She had
no college education but had two years of nursing school
and two years of nurse anesthetist school. She had total
disdain for any anesthesiologist. She would go to CRNA
meetings and come back with renewed vigor, and during
her down time between cases would fax every U.S. and
Florida congressman about issues that affected CRNAs.
I would cringe whenever she came back from these meetings
because I knew what her attitude would be for the next
weeks ahead. What amazed me though was that whenever
she had a difficult case, she would never hesitate to
ask me what to do or for me to do the case myself.
On the other hand, the next CRNA that I hired was in
her 40s. She had a four-year college degree, had a master’s
degree in nursing and then had gone on to nurse anesthetist
school. She never had that defensive attitude of the
older CRNA, and there was never any ill feeling between
us.
Older nurse anesthetists really believe that anesthesia
is a nursing profession and not a physician’s
profession. Until they get over this attitude, ASA will
never be able to come to agreement with AANA about anything,
even patient care issues. And the people who really
lose out are the patients, which is a darn shame.
Shari M. Yudenfreund-Sujka, M.D.
Winter Park, Florida
Research
Not the Only Skill That Keeps Departments Healthy
r.
Charles W. Otto, among many well-qualified others, has
suggested that the “lack of experience in the
research arena among anesthesiology chairs may be an
impediment to developing an academic environment that
promotes research.” On the contrary, I believe
it is time someone pointed out that university departments
don’t have medical research as their primary function
and that failure of a department in its more traditional
role destroys the research program as well.
With the greatest respect for Dr. Otto and the others
who have espoused this position, I must disagree with
the implication that only experienced research scientists
have the skill sets to lead our departments. In fact,
I believe this concept is dangerous to the future of
the specialty. Please note: We are a clinical medical
specialty! Research skills are not necessarily transferable
to management of clinical services, finances, personalities,
resources and education, just as someone with top clinical
and management skills may not necessarily perform well
as a scientist.
Some of our most successful departmental chairs (Kampine,
Miller(s), Reves, etc.) have certainly been fantastic
scientists, true, but other scientists have proven in
the past to be disasters in the chair role. Nor is it
accurate to assume that a chair who has never received
NIH money will not be vigorous and effective in support
of research. Examples abound.
“Can’t we all just get along together”
(and respect one another’s skills and roles)?
Bradley E. Smith, M.D.
Nashville, Tennessee
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