Don’t Sleep on Your Anesthesiology Case

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Quick! Name me the medical specialty with the most critical role in patient care.

I’m guessing you might have identified cardiology, neurosurgery, maybe emergency medicine? Maybe you thought of obstetrics. How many specialties would you list before you’d reach anesthesiology? There’s a common misconception about anesthesiology being a lazy specialty—one that pays well and allows a physician to spend her days sitting in operating rooms completing sudoku puzzles or crosswords. And sure, maybe that’s part of it.

But consider this: How long can a person survive without a clear airway? Permanent brain damage may begin after as few as 3 minutes without oxygen and death can occur as soon as 4-6 minutes. Because airway management is the heart of anesthesiology, it often falls to the anesthesiologist to handle these critical minutes after a patient’s airway fails. The hospital anesthesiologist bears the responsibility and challenge of keeping a cool head during these life-or-death moments.

As with any specialty, principles of good anesthesiology practice have evolved with developments in science and technology. The hospital anesthesiologist is expected to keep up with current principles and to follow them in her daily practice. If an anesthesiologist fails to follow the principles of good practice, she may be legally responsible for severe injury or death to a patient. Moral of the story for the plaintiff’s attorney: Don’t ignore the anesthesiology case that comes through your door. Take another look at your current case inventory and make sure you haven’t overlooked an anesthesiology case.

The hospital anesthesiologist has several primary roles, including: positioning the patient for surgery, dosing and administrating medications during surgery; monitoring vital signs; managing pain and level of consciousness; and managing the airway, such as establishing artificial or surgical airways. I’d like to focus on airway management. I am currently litigating a medical malpractice case for the death of a 30-year-old woman who died following a successful elective surgery because of negligent post-operative airway management. Here are some of the practice pointers I’ve learned:

  1. Anesthesiologists are the airway experts. If your patient is in a critical care setting, her care is probably being managed by doctors from a variety of specialties. An anesthesiologist is the most qualified to manage the patient’s airway. Other specialists such as critical care medicine, ENT, or otolaryngology will also have training and experience with airway management. But especially for the patient with a difficult airway, anesthesiology should be brought onto the care team and should be quarterbacking any airway management.
  1. The anesthesiologist must carefully evaluate the patient’s airway before surgery or intubation. The consciousness-altering and muscle-paralyzing medications used to induce general anesthesia usually take away a patient’s ability to breathe for herself, requiring the placement of an endotracheal tube down the patient’s “windpipe” so that a mechanical ventilator can do the work of breathing for the patient. For most patients, intubation will hopefully be a fairly straightforward process. But anesthesiologists must stay on the lookout for patients with “difficult airways.” A thorough pre-operative evaluation is necessary to catch the indicators that an anesthesiologist will have a difficult time getting the patient intubated. This evaluation should include taking the patient’s history, conducting a physical examination, reviewing prior surgery records, and looking at laboratory test results.
  1. Once a patient has been identified as having a difficult airway, the anesthesiologist must plan and execute an appropriate approach to maintain the airway. There are a wide variety of tools and techniques available to the hospital anesthesiologist to establish an artificial airway. Using these various methods and tools is the bread and butter of an anesthesiologist’s training. Not every technique will be right for every patient. The hospital anesthesiologist must select the best approach considering the patient’s unique history, anatomy, and medical condition. Airway management is not one-size-fits-all. Intubation may be accomplished with a traditional “direct” approach, in which the doctor uses equipment that allows her to directly visualize the entrance to the trachea at the vocal cords. Newer technology gives doctors the option to use scopes with camera equipment that allows the doctor to see the vocal cords on a screen. Scopes can be introduced through the mouth or nose. Intubation can be accomplished with the patient awake or “asleep” under general anesthesia. Awake flexible fiberoptic intubation is generally recognized as the gold standard for patients with predicted difficult airways.

 Planning for intubation must also include establishing the Plan B or Plan C if the first approach should fail. When laryngoscopic intubation fails, the anesthesiologist’s Plan B should be a supraglottic airway, a type of device that sits above the trachea and assists with delivering oxygen to the lungs. If both of these fail and the patient is not being adequately ventilated, the team must be ready to transition immediately to a surgical airway (e.g. cricothyrotomy or tracheostomy). When a patient has a known difficult airway, a physician capable of performing a surgical airway should be on standby. Remember, minutes matter.

The anesthesiologist has a critical role in patient care, and positive outcomes are never guaranteed. As with any specialty, an anesthesiologist can do everything right and a patient can still be injured or die. But we advance patient safety when we hold anesthesiologists accountable to stay up-to-date, to thoroughly assess, and to thoughtfully plan. On that note, I’ll leave you… There’s a good crossword puzzle calling my name.

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