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Con: Cardiac anesthesia and elitism: Where does SIGMA end and ROA begin?
Con: Cardiac
Anesthesia
and Elitism:
Where Does SIGMA
John H. Tinker,
0
NE OF OUR faculty, who wishes to remain anonymous, invented an acronym, namely “SIGMA” to stand for “Society for Isolation and Glorification of Myocardia1 Anesthesiologists.” The other acronym used in this communication, namely ROA, stands for “regular old anesthesiologist.” With that as background, please consider the following scenario, which takes place at 3:00 AM. Mr Smith, who is 63 years old, has undergone a quadruple-vessel CABG during yesterday’s surgical schedule, and is bleeding. The decision has been made to re-operate. His blood pressure briefly dipped to 87/67 mmHg and a tentative diagnosis of “tamponade” is being entertained. The ROA on cal1 in the hospita1 does not have SIGMA credentials. There is a SIGMA member on cal1 at home. From an anesthesia standpoint, what is actually involved with this re-operation for bleeding? Differential diagnosis of hypotension, airway management, fluid, blood and electrolyte replacement, arrhythmia control, blood gas management, obliteration of awareness, analgesia, and muscle relaxation are some of the most likely elements involved. ROAs work quite effectively in al1 these arenas daily. The cardiac anesthesiologist who believes that he or she somehow has a priori extra expertise in these areas is naive (and wrong). A true blue SIGMA member presented with the above argument wil1 solemnly intone, “Ah, but what if this patient needs to go back on cardiopulmonary bypass?” Can an ROA provide competent and safe care for such a case, which suddenly needs CPB? During cannulation, severe bleeding andior hypotension can occur. Hemodynamic and fluid management are again required. During CPB, the argument goes that a SIGMA member is needed because he or she wil1 know the proper arterial pressures at each stage of the procedure. Actually, that knowledge does not yet exist. Can the ROA remember to give heparin‘? Usually the perfusionist (1) calculates the dose; (2) fills the syringe; and (3) measures activated coagulation time (ACT) and wil1 keep track of when the heparin was given, as wel1 as the effects of the heparin on the ACT. What about the all-important period during emergence from CPB? How many cardiac anesthesiologists actually make independent decisions to start specific inotropes without at least consulting with the surgeon during this crucial period? Not many. How many cardiac anesthesiologists actually merely follow pharmacologic orders from the surgeon during this critical period? If an anesthesiologist claims to be a “cardiac anesthesiologist” but simply awaits surgical orders for dopamine, isoproterenol, epinephrine,
From the Depattrnent of Anesthesia, University of Iowa College of Medicine, Iowa City, IA. Address reprint requests to John H. Tinker, MD, Department of Anesthesia, Universi~ sf Iowa College of Medicine, Iowa City, IA 52242.
630
End and ROA Begin?
MD
or anything else during emergence from CPB, then how much expertise is the SIGMA member really adding? Could our ROA start an epinephrine infusion if asked by the surgeon? What about post-CPB management‘! This involves bleeding, arterial pressure support if low and control if high, airway management, blood gases, coagulation managrment, plus obliteration of awareness, analgesia. and muscle relaxation. Perhaps there are ROAs who do not remember that protamine drops blood pressure and should be given slowly, but surely most do. Items like fresh frozen plasma, platelets, epsilon aminocaproic acid, and desmopressin are given by ROAs in other operations. Pulmonary artery catheters are also used regularly by ROAs. Transport at thr end of the case, with lots of lines and tubes, requires continued vigilante and physiologic management. The next argument made by the SlGMA membership is that the “heart room” contains al1 sorts of specialized monitoring equipment, much of which wil1 be unfamiliar to the ROA, who, therefore, might be unable to administer safe anesthesia. There is some truth to this argument. in the sense that it can be a self-fulfilling prophecy. If the leadership in the hospital’s anesthesia department has permitted the SIGMA members to produce a gadget-fìlled labyrinth in the “heart room” filled with instruments not permitted to be used by anyone else, then this has become a self-fulfilling prophecy. This is invalid. If a person has a special ski& that ski11 ought to be used, nurtured, and continually advanced. If the only “special skill” is the ability to use a fancier monitor than is present in the ROA rooms, this is not much of a special skill. There is responsibility that must be taken by ROAs here. If the SIGMA people are buying fancy new monitors for “their” operating rooms, they should be regularly instructing the ROAs on how to use them, and the ROAs should be willing to learn how to use them properly. This is a dangerous statement for me to make, because of my administrativc position; once the ROAs learn how to use a SIGMA monitor, they usualiy want the same in al1 the ROA rooms. They make strange noises, backed up by data, about also having sick patients. The next issue is cxquisitely sensitive. Every surgeon has a “comfort level” vis-5-vis anesthesiology. Some cardiac surgeons get quite nervous when they see an unfamiliar face across the ether screen. In many hospitals, this translates into demands that al1 their cases receivc special consideration, ie, someone who is a “specialist.” In many ways, these demands are insulting to their own surgical colleagues. The patient who has been thrown out of a car during an auto accident and has all sorts of injuries, some of which are yet to be revealed, may be a far greater challenge for both surgery and anesthesiology (not to mention nursing) than is the above redo-CABG. Why should the other surgeons (cg. orthopedics, ophthalmology, ears, nose, and throat) permit their cardiac surgical colleagues to loudly demand (and get)
Journalof Cardiothoracic
and VascularAnasthas/a, Vol 6, NO 5 (October), 1992: pp 630.632
CON
their own private anesthesiologists without equal privilege for themselves? Some have, of course. In truth, for the case mentioned above and in many similar kinds of emergency or urgent cardiac cases, there is no known medical outcome-related justification for insisting upon a SIGMA member. There is no politica1 justification either unless al1 the other surgeons in the institution have equal constant access to their own private personal anesthesiologists. This extreme, with each surgeon having a list of private anesthesiologists, does occur. This is neither efficient, safer, nor tost-effective delivery of anesthesia care. The next issue is the so-called “double standard.” In a hospita1 where SIGMA members do the elective (and most of the urgent and emergent) cardiac cases during the day, and in the evening, there is “only” an ROA (who might or might not be a SIGMA member), on call, can the department legitimately be accused of switching to a lower leve1 of expertise at night? Is this a double standard? The answer to this is simple. The reader undoubtedly noticed that the case 1 presented above was chosen with care. The case presented above was not a “double-secret probational redo-Fontan” for tricuspid atresia in a 2-year-old. The case chosen was an emergency. The patient might wel1 have been hypotensive andior severely bleeding. My argument is that for a large majority of valid cardiac surgical cases, which should be done emergently, there is plenty of expertise needed, no question. ROAs do possess that expertise. The special expertise possessed by people who do primarily or exclusively cardiac anesthesia during prime time wil1 not be needed for the case presented above, even if CPB is required. For the above-mentioned “double-secret probational redo-Fontan,” the ROA on cal1 should cal1 in help, assuming the case is really emergent. These “emergent” cases have sometimes been cancelled when the surgeon discovered a non-SIGMA member was on call. Some emergency! 1 have no problem calling in help when it is needed. My ROA partners are to be trusted to know when they need help, just as 1 should be trusted to know when to cal1 in help in obstetrics. There should not be a rigid rule that a “cardiac anesthesiologist” must be there whenever a “cardiac surgeon” does anything. The above-described system does not represent a double standard. If the “heart room” is set up with Star Wars equipment, and no ROA has been permitted to touch it, let alone understand its “knobology,” then to force the ROA into that room would represent a double standard, not otherwise. This issue is, of course, highly politica]. If our anesthesia departments are to be split into smal1 subgroups that are really attached to groups of surgeons, then have these groups of elitist anesthesiologists simply become appendages of surgery? There are some of US left who remember the problems we had as a specialty when we were divisions of surgery. The anesthesiologist must be an independent advocate for her/his patient. Any kind of politica1 or financial arrangement that jeopardizes an anesthesiologist’s ability to perform independent medical advocacy
631
should be opposed. Some wil1 say, “Tinker is simply talking from an ivory tower.” Actually, nuances of various “arrangements,” which exist among anesthesiologists, hospitals, and surgeons, are wel1 known (and certainly also found) in the august halls of academe. The true test of the medical ethic remains whether or not under al1 circumstances the anesthesiologist can act as an independent medical advocate for her/his patient without retribution. By retribution, 1 mean everything from verba1 or physical abuse to loss of referrals or privileges. When we surrender our mandate to be independent medical advocates for our patients, we jeopardize our ability to be physicians. This is a critical aspect of this whole controversy. If we cannot or do not act like doctors, it is difficult to see how we can escape the “technologist” label, which some would hang on USright now. If we become, in essence, employees of, or subcontractors to, particular subgroups of surgeons, we risk loss of our ability to make the important contributions of which we know we are capable every day. The concept that a physician anesthesiologist must be an independent medical advocate for the patient would get little argument from anesthesiologists, whether SIGMA or ROA. SIGMA members who refuse to do ROA and who demand that no one invade their territory may now be saying, defensively, “1 am an independent medical advocate for my patients . . . no one pushes me around.” 1 do hope your statement is true to yourself. Cardiac anesthesiologists who are closely allied with particular surgeons or groups of surgeons have not necessarily abdicated or compromised their independent medical advocacy. Unfortunately, such attachments and arrangements can produce powerful bias. The negative aspect of that bias is related to our ability to be independent medical advocates. The operating room is one of the few places where two or more medical professionals (and one or more nursing professionals) regularly watch each other work, closely. (The delivery room is worse-three medical specialties plus nursing). Cardiac operating rooms have often become places where turf assertions, called “power trips” by the younger generation, take place with alarming frequency and disturbing consequences. Power in many hospitals has to do with the volume of patients brought in, especially for procedures. The surgeon brings them in. The anesthesiologist does not (at least into the “heart room”). From that perspective, the “starting power level” is grossly unequal in the “heart room.” Add to this the profitability factor, namely the fact over the last decade that more or less routine cardiac cases have been among the most profitable operations performed in any hospita& and there is a situation ripe for loss of independent medical advocacy by the anesthesiologist. If (when) independente is lost, real quality is undoubtedly lost. It is difficult to prove, but few anesthesiologists believe that their experience, skill, and training are of no added positive consequente. Surgical domination is often worse in the “heart room” than elsewhere, perhaps because of profitability-related power
632
factors. Each anesthesia/surgical procedure internal set of checks and balances.*
should have an
*In the aviation industry, the “captain is the absolute boss” doctrine of the past has been replaced by “cockpit resource management,” where the captains are stil1 “boss” but are mandated to at least listen to crew suggestions, and, further, are mandated to do so without retribution of any sart. They are far ahead of many of our (cardiac) operating rooms. A copilot (anesthesiologist) who is sufficiently intimidated for whatever reason, cannot be expected to take professionally responsible safety and efficacy-related positions openly. Therefore, the captain must be right, without help, every time. The reader who is a SIGMA member wil1 probably have difficulty with the above cockpit analogy, but it is food for thought.
1 am not advocatmg that ROAs do every cardiac surgical emergency. 1 am advocating that the anesthesia depart mcnts should decide, on medical grounds, who wil1 anesthctizc which emergency case. 1 am not advocating ROA anesthesia for emergency cardiac surgical cases merely to assert our independente or “rights.” We must understand the fact that surgeons are our internal customers who we do need to serve as we serve our primary (externai) customers. the patients. However, we must maintain a balance and maintain a position that wil1 allow anesthesiologists, inciuding cardiac anesthesiologists, to continue to make the critical positive contributions to perioperative patient care for which we have trained and worked so long and hard and of which we are so capable.
Anesthesia
and Elitism:
Where Does SIGMA
John H. Tinker,
0
NE OF OUR faculty, who wishes to remain anonymous, invented an acronym, namely “SIGMA” to stand for “Society for Isolation and Glorification of Myocardia1 Anesthesiologists.” The other acronym used in this communication, namely ROA, stands for “regular old anesthesiologist.” With that as background, please consider the following scenario, which takes place at 3:00 AM. Mr Smith, who is 63 years old, has undergone a quadruple-vessel CABG during yesterday’s surgical schedule, and is bleeding. The decision has been made to re-operate. His blood pressure briefly dipped to 87/67 mmHg and a tentative diagnosis of “tamponade” is being entertained. The ROA on cal1 in the hospita1 does not have SIGMA credentials. There is a SIGMA member on cal1 at home. From an anesthesia standpoint, what is actually involved with this re-operation for bleeding? Differential diagnosis of hypotension, airway management, fluid, blood and electrolyte replacement, arrhythmia control, blood gas management, obliteration of awareness, analgesia, and muscle relaxation are some of the most likely elements involved. ROAs work quite effectively in al1 these arenas daily. The cardiac anesthesiologist who believes that he or she somehow has a priori extra expertise in these areas is naive (and wrong). A true blue SIGMA member presented with the above argument wil1 solemnly intone, “Ah, but what if this patient needs to go back on cardiopulmonary bypass?” Can an ROA provide competent and safe care for such a case, which suddenly needs CPB? During cannulation, severe bleeding andior hypotension can occur. Hemodynamic and fluid management are again required. During CPB, the argument goes that a SIGMA member is needed because he or she wil1 know the proper arterial pressures at each stage of the procedure. Actually, that knowledge does not yet exist. Can the ROA remember to give heparin‘? Usually the perfusionist (1) calculates the dose; (2) fills the syringe; and (3) measures activated coagulation time (ACT) and wil1 keep track of when the heparin was given, as wel1 as the effects of the heparin on the ACT. What about the all-important period during emergence from CPB? How many cardiac anesthesiologists actually make independent decisions to start specific inotropes without at least consulting with the surgeon during this crucial period? Not many. How many cardiac anesthesiologists actually merely follow pharmacologic orders from the surgeon during this critical period? If an anesthesiologist claims to be a “cardiac anesthesiologist” but simply awaits surgical orders for dopamine, isoproterenol, epinephrine,
From the Depattrnent of Anesthesia, University of Iowa College of Medicine, Iowa City, IA. Address reprint requests to John H. Tinker, MD, Department of Anesthesia, Universi~ sf Iowa College of Medicine, Iowa City, IA 52242.
630
End and ROA Begin?
MD
or anything else during emergence from CPB, then how much expertise is the SIGMA member really adding? Could our ROA start an epinephrine infusion if asked by the surgeon? What about post-CPB management‘! This involves bleeding, arterial pressure support if low and control if high, airway management, blood gases, coagulation managrment, plus obliteration of awareness, analgesia. and muscle relaxation. Perhaps there are ROAs who do not remember that protamine drops blood pressure and should be given slowly, but surely most do. Items like fresh frozen plasma, platelets, epsilon aminocaproic acid, and desmopressin are given by ROAs in other operations. Pulmonary artery catheters are also used regularly by ROAs. Transport at thr end of the case, with lots of lines and tubes, requires continued vigilante and physiologic management. The next argument made by the SlGMA membership is that the “heart room” contains al1 sorts of specialized monitoring equipment, much of which wil1 be unfamiliar to the ROA, who, therefore, might be unable to administer safe anesthesia. There is some truth to this argument. in the sense that it can be a self-fulfilling prophecy. If the leadership in the hospital’s anesthesia department has permitted the SIGMA members to produce a gadget-fìlled labyrinth in the “heart room” filled with instruments not permitted to be used by anyone else, then this has become a self-fulfilling prophecy. This is invalid. If a person has a special ski& that ski11 ought to be used, nurtured, and continually advanced. If the only “special skill” is the ability to use a fancier monitor than is present in the ROA rooms, this is not much of a special skill. There is responsibility that must be taken by ROAs here. If the SIGMA people are buying fancy new monitors for “their” operating rooms, they should be regularly instructing the ROAs on how to use them, and the ROAs should be willing to learn how to use them properly. This is a dangerous statement for me to make, because of my administrativc position; once the ROAs learn how to use a SIGMA monitor, they usualiy want the same in al1 the ROA rooms. They make strange noises, backed up by data, about also having sick patients. The next issue is cxquisitely sensitive. Every surgeon has a “comfort level” vis-5-vis anesthesiology. Some cardiac surgeons get quite nervous when they see an unfamiliar face across the ether screen. In many hospitals, this translates into demands that al1 their cases receivc special consideration, ie, someone who is a “specialist.” In many ways, these demands are insulting to their own surgical colleagues. The patient who has been thrown out of a car during an auto accident and has all sorts of injuries, some of which are yet to be revealed, may be a far greater challenge for both surgery and anesthesiology (not to mention nursing) than is the above redo-CABG. Why should the other surgeons (cg. orthopedics, ophthalmology, ears, nose, and throat) permit their cardiac surgical colleagues to loudly demand (and get)
Journalof Cardiothoracic
and VascularAnasthas/a, Vol 6, NO 5 (October), 1992: pp 630.632
CON
their own private anesthesiologists without equal privilege for themselves? Some have, of course. In truth, for the case mentioned above and in many similar kinds of emergency or urgent cardiac cases, there is no known medical outcome-related justification for insisting upon a SIGMA member. There is no politica1 justification either unless al1 the other surgeons in the institution have equal constant access to their own private personal anesthesiologists. This extreme, with each surgeon having a list of private anesthesiologists, does occur. This is neither efficient, safer, nor tost-effective delivery of anesthesia care. The next issue is the so-called “double standard.” In a hospita1 where SIGMA members do the elective (and most of the urgent and emergent) cardiac cases during the day, and in the evening, there is “only” an ROA (who might or might not be a SIGMA member), on call, can the department legitimately be accused of switching to a lower leve1 of expertise at night? Is this a double standard? The answer to this is simple. The reader undoubtedly noticed that the case 1 presented above was chosen with care. The case presented above was not a “double-secret probational redo-Fontan” for tricuspid atresia in a 2-year-old. The case chosen was an emergency. The patient might wel1 have been hypotensive andior severely bleeding. My argument is that for a large majority of valid cardiac surgical cases, which should be done emergently, there is plenty of expertise needed, no question. ROAs do possess that expertise. The special expertise possessed by people who do primarily or exclusively cardiac anesthesia during prime time wil1 not be needed for the case presented above, even if CPB is required. For the above-mentioned “double-secret probational redo-Fontan,” the ROA on cal1 should cal1 in help, assuming the case is really emergent. These “emergent” cases have sometimes been cancelled when the surgeon discovered a non-SIGMA member was on call. Some emergency! 1 have no problem calling in help when it is needed. My ROA partners are to be trusted to know when they need help, just as 1 should be trusted to know when to cal1 in help in obstetrics. There should not be a rigid rule that a “cardiac anesthesiologist” must be there whenever a “cardiac surgeon” does anything. The above-described system does not represent a double standard. If the “heart room” is set up with Star Wars equipment, and no ROA has been permitted to touch it, let alone understand its “knobology,” then to force the ROA into that room would represent a double standard, not otherwise. This issue is, of course, highly politica]. If our anesthesia departments are to be split into smal1 subgroups that are really attached to groups of surgeons, then have these groups of elitist anesthesiologists simply become appendages of surgery? There are some of US left who remember the problems we had as a specialty when we were divisions of surgery. The anesthesiologist must be an independent advocate for her/his patient. Any kind of politica1 or financial arrangement that jeopardizes an anesthesiologist’s ability to perform independent medical advocacy
631
should be opposed. Some wil1 say, “Tinker is simply talking from an ivory tower.” Actually, nuances of various “arrangements,” which exist among anesthesiologists, hospitals, and surgeons, are wel1 known (and certainly also found) in the august halls of academe. The true test of the medical ethic remains whether or not under al1 circumstances the anesthesiologist can act as an independent medical advocate for her/his patient without retribution. By retribution, 1 mean everything from verba1 or physical abuse to loss of referrals or privileges. When we surrender our mandate to be independent medical advocates for our patients, we jeopardize our ability to be physicians. This is a critical aspect of this whole controversy. If we cannot or do not act like doctors, it is difficult to see how we can escape the “technologist” label, which some would hang on USright now. If we become, in essence, employees of, or subcontractors to, particular subgroups of surgeons, we risk loss of our ability to make the important contributions of which we know we are capable every day. The concept that a physician anesthesiologist must be an independent medical advocate for the patient would get little argument from anesthesiologists, whether SIGMA or ROA. SIGMA members who refuse to do ROA and who demand that no one invade their territory may now be saying, defensively, “1 am an independent medical advocate for my patients . . . no one pushes me around.” 1 do hope your statement is true to yourself. Cardiac anesthesiologists who are closely allied with particular surgeons or groups of surgeons have not necessarily abdicated or compromised their independent medical advocacy. Unfortunately, such attachments and arrangements can produce powerful bias. The negative aspect of that bias is related to our ability to be independent medical advocates. The operating room is one of the few places where two or more medical professionals (and one or more nursing professionals) regularly watch each other work, closely. (The delivery room is worse-three medical specialties plus nursing). Cardiac operating rooms have often become places where turf assertions, called “power trips” by the younger generation, take place with alarming frequency and disturbing consequences. Power in many hospitals has to do with the volume of patients brought in, especially for procedures. The surgeon brings them in. The anesthesiologist does not (at least into the “heart room”). From that perspective, the “starting power level” is grossly unequal in the “heart room.” Add to this the profitability factor, namely the fact over the last decade that more or less routine cardiac cases have been among the most profitable operations performed in any hospita& and there is a situation ripe for loss of independent medical advocacy by the anesthesiologist. If (when) independente is lost, real quality is undoubtedly lost. It is difficult to prove, but few anesthesiologists believe that their experience, skill, and training are of no added positive consequente. Surgical domination is often worse in the “heart room” than elsewhere, perhaps because of profitability-related power
632
factors. Each anesthesia/surgical procedure internal set of checks and balances.*
should have an
*In the aviation industry, the “captain is the absolute boss” doctrine of the past has been replaced by “cockpit resource management,” where the captains are stil1 “boss” but are mandated to at least listen to crew suggestions, and, further, are mandated to do so without retribution of any sart. They are far ahead of many of our (cardiac) operating rooms. A copilot (anesthesiologist) who is sufficiently intimidated for whatever reason, cannot be expected to take professionally responsible safety and efficacy-related positions openly. Therefore, the captain must be right, without help, every time. The reader who is a SIGMA member wil1 probably have difficulty with the above cockpit analogy, but it is food for thought.
1 am not advocatmg that ROAs do every cardiac surgical emergency. 1 am advocating that the anesthesia depart mcnts should decide, on medical grounds, who wil1 anesthctizc which emergency case. 1 am not advocating ROA anesthesia for emergency cardiac surgical cases merely to assert our independente or “rights.” We must understand the fact that surgeons are our internal customers who we do need to serve as we serve our primary (externai) customers. the patients. However, we must maintain a balance and maintain a position that wil1 allow anesthesiologists, inciuding cardiac anesthesiologists, to continue to make the critical positive contributions to perioperative patient care for which we have trained and worked so long and hard and of which we are so capable.