Volume 5, No. 1 • Spring 1990

Bus Driver Better Model

Hansel de Sousa, M.D

To the Editor

The reappearing analogy between anesthesia and cormner6al aviation is far too presumptuous to support the current trend of upgrading or replacing equipment and anesthetic techniques in the name of safety. The 50 year old DC3 is still being used by numerous charter and scheduled airlines; safety is not one of the major reasons for the popularity of the DC IO, whose development is so far advanced from the earlier aircraft that there is no analogy to the development of anesthesia.

After all, most of our anesthetic machines still depend on turn of the century technology of glass rotameters, needle control valves and plenum vaporizers, albeit with some modifications. True, the relatively recent use of polypharmacy, electronic monitors, and expensive apparatus is breathtaking, but usually at the expense of the development of clinical skills and, with the possible exception of pulse oximetry, of no measured benefit.

The raison d’etre of commercial aviation is safe transportation, * as the raison d’etre of anesthesia is safe surgery. But even with today’s impressive jumbo jets, one is still able to choose more basic, and probably less safe forms of transportation, such as walking, the bus, or a train.

My favorite analogy to the anesthesiologist is the endangered Pittsburgh jitney driver. The patient, rather than being the passenger, is the automobile. Usually in good repair, occasionally having seen better times, but by necessity, always intimately understood by its driver, who has developed a confident “feel” for his patient by utilizing his senses and perhaps the few basic safety monitors of engine oil pressure, temperature, and fuel reserves. At one time he had to compete for his passengers by providing an excellent service; but now his passengers are the regulatory agencies, insurance companies, risk management attorneys and other taxi drivers who would rather be jumbo-jet pilots. Today’s passengers are assigned to him; often back seat drivers who forget that they used to give their operator sufficient discre6on and incentive to get them to their destination as efficiently as possible. In order to keep his passengers happy, today’s driver is highly regulated and his numbers strictly controlled. He needs to paint his vehicle yellow and uses a taximeter to determine his fare. He needs air conditioning that strains the engine further, and a two-way radio that often relays confusing messages. Delays are commoner, costs are higher and the public unhappier.

A safe practice that stimulates innovation is encouraged by less, rather than more regulation. The enforcement of published standards of care as well as the assignment of exclusive hospital contracts fosters a mediocre anesthetic practice. There’s little wrong with cultivating quality by allowing individual discretion and healthy competition, with patients and their advocates being the best judges of a good anesthetic.

To keep in perspective with ordinary living and to keep costs down by weeding out the superfluous from the useful, anesthesiologists should have to contribute to the cost of equipment and supplies. (Would you comply with published standards of care and routinely use a cardioscope for all healthy patients if the ECG electrodes cost three times as much as your lunch?) Of course, some anesthesiologists will find themselves with plenty of free time to upgrade their skills and knowledge, but that’s probably why we’re in this regulatory mess in the first place.

Hansel de Sousa, M.D. Pittsburgh, PA