To the Editor:

I read the recent APSF edition regarding fatigue and sleep deprivation with great interest as I myself struggled to stay awake one morning after call. It occurred to me that in my 20 years of practice that by far the greatest cause of fatigue, stress, and sleep deprivation to me has been the escalating and incessant demands of obstetrical anesthesia and specifically labor epidurals. The evolving standard of “every woman in labor deserves an epidural upon request” has enabled a small subgroup of patients to consume a disproportionately large amount of available anesthesia manpower. What was once a privilege of a few has become an entitlement to all and a tremendous drain on anesthesia resources.

I would estimate that labor epidurals represent less than 5% of patient volume and reimbursement to us nationwide but account for greater than 50% of the demand for after hour anesthesia services.

If we, as a specialty, are serious about addressing the problem of fatigue caused by sleep deprivation, the obvious place to start would be to re-evaluate our professional obligation to perform these underfunded and non-essential procedures after hours.

The standards set for us by hospital administrators, obstetricians, and our own ASA, regarding provision of labor epidural analgesia are not feasible in hospitals where anesthesia providers must work the next day following call. Total ablation of labor pain is a noble goal, but the cost to anesthesia providers in monetary and physical expenditure far exceeds the reimbursement. We should not have to “burn the candle at both ends” in order to appease one overly demanding group of patients by night and risk detriment to others who are entitled to our best efforts by day. Those of us in small groups who toil under these conditions could use some relief. I hope ASA and APSF policy makers are listening and can help in this regard.

Sincerely,
TH Parker, Jr., MD
Memorial Hospital
Bainbridge, Georgia

To the Editor:

Fatigue Swallows Up Vigilance back to top

I am writing in response to the topic of fatigue and the practice of anesthesiology. It has been said that common sense cannot be taught in schools. Fatigue and performance are negatively correlated, as we all know from the admonishments to get a good night’s rest before exams. Don’t patients deserve even more consideration? Overworked doctors and medical errors have been a flashpoint for discussion ever since I was a resident 18 years ago. And we are still doing research to find out how many medical errors are committed while fatigued.

Why do we need more studies to prove this? Do you really think that the true incidence of death or permanent injury will be discovered this way without exposing individuals, administrators, and hospitals to liability? I’ve learned all I need to know about vigilance as a truck driver. Vigilance is necessary to prevent accidents. Fatigue swallows up vigilance. But there’s more. Fatigue depletes our cognitive power, diminishes our ability to retrieve critical information, and betrays our best intentions. We fail to see the obvious treatment and anesthetic options when fatigued. And even if we do, the energy to act on the knowledge of the best treatment plan is gone.

I find no reason for this continuing dialogue – fatigue and what to do about it other than an economic one: it costs more to hire additional people. Yet the economic costs of decreased productivity from injury due to medical errors is in the billions of dollars. Until our leadership recognizes that this is money we pay for as a society, which eventually impacts on our health care costs and our compensation, this cognitive dissonance will continue. As a matter of conscience, I as an individual will manage my fatigue in a way that occurs commonly, if covertly. I will not relieve my colleagues for breaks on certain occasions, nor will I accept responsibility to conduct an anesthetic for their ASA class IV patient just to facilitate the OR schedule. I will take my time to answer my pages. I will not move any faster to do endoscopy cases just because someone has just decided to add on 3 more cases to an already full schedule. Without the element of risk, we can all be the good Samaritans that we imagined ourselves to be when we applied to medical school. With risk, everything changes. Let us stand up and fight to protect our patients instead of finding yet another way to bend over and accommodate an overly demanding system, because the next bending over may just break our backs.

Herb Lee, MD
North Brunswick, NJ

To the Editor:

Anesthesia Technicians Are Professionals Too back to top

I would like to clarify for the readers of this publication who may have been offended by the comment made in response to an article in the Winter 2004-2005 issue of your newsletter, “Reader Calls for Professionalism.” I quote, “I would like to think that we are all professionals and not just technicians.” The definition of a technician is: a) of, relating to, or characteristic of a profession; b) engaged in one of the learned professions; c) characterized by or conforming to the technical or ethical standards of a profession.

Why would a reader feel the need to respond to the comment about “being a professional and not just a technician”? The APSF Newsletter is read by many anesthesia technicians who wish to enhance their knowledge in their profession of anesthesia. The need for anesthesia technicians in the field of anesthesia has grown tremendously, and as it continues to grow, the skills must continue to improve in order to provide the safest environment for the providers and the patients who rely on the professionals in the field of anesthesia. “Just a technician” implies that technicians are not a valuable asset to the anesthesia team. This was clearly not the intent of the writer. I would like to think that the reason for reading this publication is to further our knowledge in our profession, thereby eliminating the possibility of repetitive, career-ending mistakes, and gaining the knowledge needed to give patients the best and safest care possible while their lives are in our hands.

I will continue to increase my knowledge as an anesthesia technician by reading this publication and any other publication that may benefit my profession. After all, this is what a technician must do: to be a professional!

Daniel A. Clark, Cert. A.T.
Jacksonville, FL

Editor’s Note:
We would like to apologize for any negative connotation to Mr. Clark and to the many professional anesthesia technicians who contribute their important skills and effort to patient care.

To the Editor:

Monitoring Neuromuscular Blockade Often Overlooked back to top

I am not a constant reader of the APSF Newsletter so perhaps I've missed the APSF’s position on this topic; nevertheless, I think it represents a subject worthy of APSF attention. As a supposed “authority” on the clinical use of neuromuscular blocking agents (NMBA), I still come across clinicians who opine, “I haven't used a peripheral nerve stimulator (PNS) in 20 years and I see no reason to start now.” On a recent visit to a well respected academic medical center, the anesthesiologist in charge of pediatric anesthesia told me that he never uses PNS units since they “don't work in kids.”

While a recent editorial opinion (Anesthesiology 2003;98:1037-9) certainly does not support these ideas, I am unaware of any published clinical guidelines by organizations such as the APSF or the ASA on the subject. I think the time has come for these societies to clearly state that the administration of nondepolarizing relaxants in the absence of neuromuscular monitoring represents substandard care.

In a letter to a correspondent, I noted in part. . .

"I agree that there are only limited outcome data (Acta Anaesthesiol Scand 1997;41:1095-1103) to suggest that patients who arrive in the PACU with TOF ratios of 0.50, for example, have a significantly increased morbidity or mortality compared to individuals who have attained a TOF ratio > 0.80. To prove this thesis would require a rather massive project that is not likely to be funded. However, anesthesiology as a specialty has been lauded for the drop in anesthesia risk, which has been documented over the last 20 years. Improvements in monitoring have been cited as a major determinant of this perceived improvement in outcome. Nevertheless, there is little evidence-based data that clearly show that pulse oximetry or capnography in fact reduces overall morbidity. Yes, anecdotal reports abound, but the same can be said for the use of objective neuromuscular monitoring.

"When I was a resident (over 40 years ago) we did not have or routinely use electrocardiography, pulse oximetry, capnography, anesthetic agent monitors, or cerebral-function physiologic monitors. Nor did we miss them. Now I would feel naked without them. Do I use the TOF-Watch or the Datex M-NMT module in every case where nondepolarizing blocking drugs are administered? No. However, I sincerely believe that this monitoring modality should be routinely available to the anesthesiologist. My experience suggests that it is a great pedagogical tool. What it teaches is that clinical judgment is often wrong.”

Aaron F. Kopman, MD
New York, NY

To the Editor:

Noise Pollution Obscures Pulse Ox Tone back to top

?Noise Pollution Obscures Pulse Ox Tone
To the Editor:
While I agree that the pulse oximeter tone, alarms, and so forth should be audible and that the pulse oximeter tone should reflect the patient's oxygen saturation, it is often VERY difficult to hear these sounds over the 80-90 decibel sound pressure level of the music being blasted by the surgeons (and, unfortunately, now the anesthesia teams).

We need a limit on the volume of the “music” that is played in the OR. Often, when I am doing a case where I have had to place a temporary pacemaker (like a pacemaker-dependent patient having a mastectomy overlying the generator), many of the surgeons play music loudly enough that I have to turn it down myself.

It is only a matter of time before someone (the patient) gets hurt.

Marc A. Rozner, PhD, MD
Houston, TX