Observations: At the Forefront of Patient Safety

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May 1, 2013 Volume 77, Number 5
Observations: At the Forefront of Patient Safety N. Martin Giesecke, M.D. Editor, ASA NEWSLETTER

Anesthesiologists have been in the forefront of matters of patient safety for more than 60 years. Most of us are familiar with the monitoring advances that occurred in the 1980s, especially pulse oximetry and capnography, all of which played an important part in improving the safety of anesthetic care. In the mid-1980s, ASA initiated the Closed Claims Study, a scientific review of anesthesia-related medical liability claims that has taught us much about adverse anesthetic outcomes. Looking at the causes of these unexpected results has enabled us to implement prevention measures. About this same time, anesthesiologists at Harvard formed a committee to review the etiology of anesthetic accidents at that institution. The Harvard committee came up with the first standards for minimal intraoperative monitoring. These standards were revised and adopted by ASA in October 1986 as the society’s first practice standard, STANDARDS FOR BASIC ANESTHETIC MONITORING. Anesthesia machine developments occurred that helped prevent human error – nonadjustable minimal oxygen/nitrous oxide ratios, low airway pressure alarms, rising ventilator bellows, etc. And the FDA anesthesia machine checkout list was adopted.

We have continued to make advances since then, but I would like to comment on two advances that originated more than four decades ago. Anesthesiologists promulgated both of these safety advances, and both came about as the result of attempts to decrease the risk of morbidity and death associated with anesthesia for emergency surgical procedures. One of these practice improvements was the use of balanced salt solutions to help resuscitate trauma victims suffering from profound hemorrhage. The second was the adoption of the English practice of intubation for general anesthesia in obstetrical patients.

Well before he was a president of ASA, in 1950, M.T. “Pepper” Jenkins, M.D. published a seminal paper pro-moting the use of balanced salt solutions with whole blood transfusions.1 Dr. Jenkins was a U.S. Navy physician in World War II. He served during the Pacific Island-hopping campaign of the U.S. Marines, particularly on the island of Bougainville. This experience led him to see a significant number of war-injured military personnel with hemorrhagic shock. By the end of World War II, the standard therapy for treatment of massive blood loss was the administration of an equal amount of whole blood. Even back then, Dr. Jenkins recognized that patient morbidity and mortality was increased in direct proportion to the amount of blood transfused during resuscitation.

In 1948, Dr. Jenkins became Chairman of the Division of Anesthesiology (of the Department of Surgery) at UT Southwestern Medical School and Parkland Hospital, in Dallas, Texas. With his war experience, Dr. Jenkins had become primarily interested in the treatment of trauma victims. He and his colleagues realized that the more whole blood a patient received for resuscitation, the more likely that patient was to develop pulmonary vascular congestion. This congestion led to progressive hypoxemia from a functional atelectasis and (in many patients) death. Dr. Jenkins’ paper1 was the first to promote the use of balanced salt solutions (in the late 1940s and early 1950s; only lactated Ringer’s was available to fit this bill) for the resuscitation of trauma patients. We all understand the physiologic mechanism now and I will agree that there is still controversy in the crystalloid versus colloid resuscitation arena. But in 1950, giving lactated Ringer’s solution to patients who also received whole blood transfusions was an amazing advance in patient safety.

The second advance in patient safety started in England, but made its way across the pond as a result of another anesthesiologist at Parkland Memorial Hospital. In 1963, when my father, A. H. “Buddy” Giesecke, Jr., M.D., finished his anesthesiology residency at UT Southwestern Medical School and Parkland Memorial Hospital, he took a job as a young faculty member working there for Dr. Jenkins. Dr. Giesecke had also been in the military, having served as a flight surgeon in the U.S. Army. He never saw combat – his tour of duty took place immediately after the Korean War, but he did serve as an aviation crash investigator. This led to an interest in trauma care and to his training at Parkland.

His first obligation as a young faculty anesthesiologist was caring for obstetrical patients. At the time, Parkland had about 12,000 deliveries per year. About 1,200 of these were the result of Caesarian section. For those patients, the standard anesthetic in the United States [in 1963] was inhalational anesthesia by the mask, using cyclo-propane. Of course, inhalational anesthesia in obstetrical patients was fraught with the risk of aspiration and death. Dr. Giesecke experienced one of those deaths during his anesthesiology training, so he was anxious about working with obstetrical patients. He decided that he was going to find a safer way to provide general anesthesia to these parturients.

Like many scholars of the time, he went to the library and did a fair amount of research. He found a paper published by J.G. Bourne that discussed using tracheal intubation for obstetric emergency patients.2 He began using the technique as described by Dr. Bourne –rapid-sequence induction, intubation and balanced anesthesia with nitrous oxide and succinylcholine. Gradually, his colleagues took up the practice and it spread across the city of Dallas. In 1967, Dr. Giesecke published a survey of the practice of obstetrical anesthesiology in Dallas County, Texas.3 Intubation of obstetrical patients requiring surgical delivery eventually spread across the rest of the United States. Of the many medical issues in which he was involved, my dad was most proud of this one. He used to say that he could not count the number of lives saved, but that it must have been significant, because we never went back to inhalational anesthesia by the mask for Caesarian delivery.

These are but two examples of how anesthesiologists have made significant impacts on patient safety. Certainly, patient mortality was the inspiration for both of these changes in medical practice. But the fact that anesthesiologists were the instigators of these practice changes is important. And anesthesiologists continue to use their medical knowledge and experience to affect improvements on patient safety to this day.

1. Jenkins MT, Jones RF, Wilson B, Moyer CA. Congestive atelectasis – a complication of intravenous infusion of fluids. Ann Surg. 1950;132(3):327-347.
2.  Bourne JG. Anaesthesia and the vomiting hazard: a safe method for obstetric and other emergencies. Anaesthesia. 1962;17(3):379-382.
3. Giesecke AH. General anesthesia for obstetrics. Dallas Med J. 1967;53:476-479.