A growing number of anesthetics are performed outside the O.R. The O.R., however, is not only our comfort zone as anesthesiologists but also the comfort zone of the anesthesia technologists and technicians. Through years of study and trial-and-error, we have created the ultimate anesthetic site with extensive monitoring as well as numerous resources to handle uncommon complications. As the liaison between ASA and the American Society of Anesthesia Technologists and Technicians (ASATT), writing an article on alternate-site anesthesia from the perspective of our techs seemed appropriate. Thousands of anesthetics are performed outside the O.R. at Penn State Hershey. Our anesthetizing sites include (but are not limited to): MRI, CT scanner, invasive radiology, radiation therapy, cardiac catheterization lab, interventional neuroradiology, adult and pediatric endoscopy suites, ICU, ER, and numerous small-procedure rooms throughout the hospital. At Pinnacle Health in Harrisburg, Pennsylvania, we provide alternate-site coverage less frequently (but the numbers are growing); therefore, there are less-established protocols and “more bugs to work out” for the anesthesiologists as well as technicians. As anesthesiologists, we expect to provide the same level of anesthesia care with the same safety mechanisms in place regardless of where we are. That puts an incredible burden on the anesthesia team as a whole.
When the anesthesia techs (thank you, anesthesia techs from Penn State Hershey and Pinnacle Health, and the board of the ASATT) were asked to list their greatest concerns, questions and comments, these were the 50 most common responses:
1. The availability of medical gases, whether piped into the location or provided by gas cylinders. Are there ample medical gas supplies to cover the case(s) to be performed? Furthermore, are the appropriate pressure-reducing devices in place?
2. If they say they don’t need it, they need it. Bring it.
3. Is there a gas scavenging system?
4. Is suction available? Is back-up portable suction present?
5. Are the hose lengths appropriate to reach the DISS connections, anesthesia machine and the patient?
6. Are there “any” electrical outlets in the room?
7. Are the necessary monitors/equipment available and compatible?
8. How long will it take for help to arrive, if needed, and do they know where to go? Don’t call a code. No one knows where we are.
9. Do the people working at the alternate sites know that it takes time to anesthetize and wake up a patient then turn over for the next case?
10. Are the anesthesiologists realistic about what can be done in a particular area?
11. Do the anesthesiologists realize that no matter what we do, it will never be just like the O.R.?
12. Is the physical space reasonable to provide a safe anesthetic? “You can’t put 14 pounds on a teaspoon.” Is there space for all the rescue equipment, carts and drugs?
13. The non-anesthesia doctors, nurses, techs do not know what we need and do; therefore, they get frustrated with us.
14. Carry gloves for you and the docs because they never have the right sizes.
15. Do schedulers realize that they cannot change the schedule without letting us know?
16. When called, sometimes the anesthesiologists forget we are not right around the corner as we are in the O.R. complex.
17. The techs have many more responsibilities when at alternate sites.
18. Scope of practice goes “out the window” since many times the techs are the second most knowledgeable individuals about anesthesia within “miles.”
19. You are more likely to have out-of-date equipment and expired drugs at alternate sites.
20. The pharmacy is never close by.
21. Is anything we have MRI-compatible?
22. Bring a full E cylinder of oxygen because it will otherwise be empty in the elevator.
23. Does anyone else there know what to do during a code, such as mask ventilating, pushing drugs or performing CPR?
24. Do we need portable computers for charting, and is there an active port for the EMR?
25. If a MAC is planned, do we have the necessary rescue devices and equipment/supplies to convert to a GA?
26. Where is the patient being recovered? Do I need to provide equipment for that as well, or transport equipment to go to the regular recovery room?
27. Where is the code cart?
28. Why doesn’t anyone know the tech phone/pager number?
29. Why are the cases done in the middle of the night?
30. I never know which lead aprons we are allowed to use.
31. We understand that there are sterile tables in the closet where we are providing anesthesia, but we have to be able to get to our docs.
32. Do we have the appropriate padding and headrests available for patient positions other than supine?
33. Replacement equipment is floors away.
34. The patients are commonly sicker and the procedure is frequently emergent at the alternate sites.
35. Invasive monitoring is sometimes necessary but logistically difficult depending on the site.
36. Do we have radiolucent ECG patches in the catheterization lab (or even in the hospital)?
37. Why do they schedule alternating adult and neonatal/pediatric patients?
38. Why is my equipment always in the way of your machines?
39. I got your page and have what you need, but where are you?
40. I always carry a flashlight, extra batteries, tape, a pair of scissors and an Eschmann Stylet.
41. How many MAC or credit cards can you lose in MRI? I remove everything metal from my pockets in the morning when I am in MRI.
42. I am always ready to crawl, climb or slide.
43. Carry a portable oximeter.
44. No one but me seems to be able to escort the parents out of the induction area.
45. Bring emergency airway equipment even when no one else thinks they will need it.
46. No one tells us when something is dangerous to us, such as in nuclear medicine or radiation therapy.
47. You always need extension tubing, I.V. and breathing circuit.
48. Why do the anesthesiologists think it’s the appropriate place to try the most “exotic” anesthetics?
49. If you store equipment at the site, it won’t be there when you come back.
50. Come to my world – see if I am nice to you.
As you can see, the anesthesia technologists and technicians have a lot on their minds and on their plates when assigned to an alternate site or multiple alternate sites (and are still able to laugh a little about it). However, without their expertise, we could not provide safe and efficient anesthetics with the ease and skill that we do (and expect) in the O.R.
A special thank you goes to Priti Dalal, M.B.,B.S., Director of Pediatric Alternate Site Anesthesia, Penn State Hershey, and the physicians of Riverside Anesthesia Associates.