Volume 7, No. 3 • Fall 1992

Apnea Issue More Important Than Monitors. Capnography Standard Assailed as Obscuring Question of Professional Judgement

William K. Hamilton, M.D.

To the Editor

The article ‘From the Literature: ‘Standards of Care and Capnography” appearing in the Summer 1991 issue of the APSF Newsletter provokes my concerns about ‘standards’ and the concepts such standards generate to the point that I must write to live with my conscience. This review of a case report in a malpractice newsletter describes another case in which an esophageal intubation resulted in severe brain injury. This led to a judgement against the hospital for not providing a capnograph in 1987 and a 4.5 million dollar award to the plaintiff.

My comments are not at all directed to the appropriateness of the award or even whether a capnograph would or would not have been essential in the management of the case. Rather, my comments are incited by the fact that in the whole discussion of this matter in the review, there is no debate or even mention concerning the decision to render this patient apneic to the extent that mechanical ventilation was required. She is described as a healthy, 36-year-old woman for elective tubal ligation. She suffered a tragic outcome as a result of poor anesthesia care and the debate seems to be exclusively about the presence or absence of an electronic monitor and whose responsibility that was.

It is my contention that a basic fault here is in the decision to render a healthy patient totally apneic for a very minor surgical procedure. At the risk of being labeled macho, I insist that complete apnea is certainly not required for tubal ligation. Cardiac arrests and/or deaths from disconnects and esophageal intubation are not likely to happen if patients can breathe on their own. Therefore, these complications must in large part be attributed to the apneic techniques of anesthesia so commonly used today. Such potentially dangerous techniques that involve their own set of complications should be used only when specifically indicated since they do add significantly to the risk of general anesthesia. The extreme emphasis on monitoring dilutes or distracts attention away from the primary risk factor inherent in the anesthetic itself.

For the profession of anesthesiology to discuss this case without even mentioning the correctness of anesthetic management is likely an inevitable consequence of mandated standards. The standards make it ‘legal’ and easy for us to blame something and someone else. To me, this is unacceptable professional behavior.

Unseen Dangers

We have come to accept and teach such clinical practices without appreciating the inherent dangers. I profess we have substituted reliance on monitors (encouraged by ‘official’ blessing from foundations and societies) for the individualization of indications and the weighing of risk-benefit ratios. Some more cynical than I might suspect an organization such as yours, which includes among its sponsors many purveyors of monitoring equipment, of a sinister method of marketing. A $4.5 million judgement will scare lots of hospitals into buying capnographs. 1, knowing you all to be above such behavior, limit my charges to grossly improper emphasis in determining the genesis of this tragedy.

I know your foundation did not render the decision and award. However, you have presented it without the above critical discussion. You have listed the questions raised without mention of the anesthesiologists professional judgement except as it relates to capnography. You have referenced the APSF Newsletter as repeatedly announcing and promoting the need for monitors. Did you ever admonish us as to the risk-benefit of apneic techniques? Have you considered ‘standards” relative to prohibiting the subjecting of patients to this risk unnecessarily?

Many people are aware that I supported the development of capnographs. I believe they can and do give us valuable information. I am seriously saddened to see them promoted to the exclusion of professional judgement.

William K. Hamilton, M.D.

University of California, San Francisco