To The Editor

Dr. Pratt’s article on medical errors and the attempts of various experts to minimize such errors in obstetric anesthesia was very interesting. There is little question that many of our problems, especially in acute, high-risk cases, arise from a lack of communication between the obstetric and anesthesia staffs. The paradigm of such lack of communication is the scenario in which a high-risk parturient is brought back to the operating room for emergent cesarean section, prepped and draped, and is about to be operated on when someone recognizes that the anesthesia team has not been called. I think it would be rather surprising were we to discover just how often this scenario is played out in real life. Clearly, the failure to notify the anesthesia team early has negative consequences for the patient as it severely restricts the anesthesiologist’s options for the provision of surgical anesthesia.

One common factor running through the suggestions of all 3 of the experts is complexity. Dr. Sachs’s training program involves major changes to traditional practice. Dr. Birnbach’s work at the University of Miami requires the use of a very expensive (more than $3 million) stimulator system for training, and Dr. Preston’s team training program also involves the use of a stimulator and major didactic innovations. While all of these programs are certainly very valuable, they are beyond the reach of many institutions, both academic and private.

We have had the usual number of communication failures in a large teaching hospital and have always utilized a form of “critical event” analysis after a bad outcome. This tends to promote communication for a relatively short period of time following the critical incident. It does not tend to change traditional patterns of behavior.

One change that has been of great help was actually suggested by the division head of maternal-fetal medicine here. He invited us, meaning the anesthesiology attending and resident covering for the day, to regularly attend their morning teaching rounds where all of the obstetric patients are discussed and any questions regarding anesthetic issues can be answered. In addition to the obvious advantage of providing our anesthesia residents with a printed list of all obstetric patients and the obstetric plans for those patients, our participation in obstetric daily teaching rounds effectively makes us a recognized part of the daily management of the patients on labor and delivery. Our presence at rounds symbolically makes us an integral part of the obstetric team. This is critical for us as we have multiple short (2-week) rotations in obstetric anesthesia for our residents, and, although we have a core of obstetric anesthesiologists, it is not unusual for someone outside that core to cover obstetrics during the day and to routinely cover at night.

We are physically separate from the main obstetric floor with an anesthesia call room and lounge next to the operating room. Without our formal involvement in morning obstetric rounds we tend to resemble a mysterious group, appearing when called, but otherwise forgotten. It is critical that we not be regarded as a merely technical “epidural service” with the unit secretary making calls to our residents like “epidural now in room 4.” In order to avoid this, we require the obstetric resident to contact our resident before the placement of an epidural. This maintains the physician-to-physician relationship and tends to lessen the perception that we are simply “needle jockeys” rather than physicians.

Although complex team teaching systems and anesthesia stimulators certainly are effective and have a place, they are not practical for many departments. For those of us who lack the resources to fund such systems, there are very simple, no-cost alternatives, which can increase the communication between obstetrician, and anesthesiologists, and may be critical to the prevention of bad outcomes. Certainly in teaching hospitals the participation of a member of the obstetric anesthesiology team in daily obstetric teaching rounds is very beneficial, as is maintaining the requirement for physician-to-physician consultation prior to labor epidural placement. Although we have not followed outcomes since the above 2 changes were instituted in our practice, we believe that they have improved the quality of care that we are able to deliver and have reduced the number of incidents in which no one calls “anesthesia” until the last moment. These are simple, no-cost changes which can be easily instituted in any teaching hospital. One more item, which we hope to make a monthly event, is a mock emergent cesarean section drill involving the labor and delivery nurses; obstetric, neonatal and anesthesia residents; and attendings. Such drills do not require any significant additional resources and can highlight potential problems before they involve a patient. They also allow each specialty to voice concerns in front of colleagues from other specialties.

Philip J. Balestrieri, MA, MD
Charlottesville, VA