In My Opinion: Are Surgeons Needed for Induction?

Edward A. Brunner, M.D., Ph.D.; Willard A. Fry, M.D.

“In My Opinion. . .” is not meant to be an official APSF editorial, but rather an opportunity for invited respondents to address interesting and controversial issues. These issures should not be geographically or institutionally unique and are meant to represent areas of broad interest and concern. The focus is to create discussions in response to thought-provoking questions. Example topics will include: “Should the surgeon be present in the OR for induction;” “Conscious sedation in the GI lab Anesthesiology roles and responsibilities.”

Newsletter readers are invited to submit questions they would like addressed, or answers to (opinions on) questions they have institutionally (or individually) dealt with.

Jeffrey S. Vender, M.D. Column Editor

Should the surgeon be in the operating mom at the time of induction of anesthesia?

Yes … I can clearly remember a personal experience over fifty years ago when, as a terrified five-and-a-half-year-old, I was wheeled into an operating room in St. Vincent’s Hospital in Erie, Pennsylvania to have my tonsils removed. The relief which I experienced was immeasurable as my surgeon, Dr. Charles Leone, greeted me: “What have we here? Mary Brunner’s oldest boy.” I put my arms around him, gave him a big hug and lay back, reassured that this trusted friend would take good care of me.

In the last fifty years medicine has changed a good bit. We have become far more technically oriented in the care we give. We have become fair more specialized. And, to some extent, we have become more impersonal. Our patients don’t criticize us for lack of knowledge; they don’t criticize us for lack of technical skill. They do criticize us for being uncaring.

This complaint underlies the loss of prestige which the profession of medicine has suffered in the last generation. To regain our lost stature we must reorient our behaviour and our attitudes. Our patients deserve the psychological support of their operating surgeon in the period immediately preceding operation.

There are other more practical reasons for the surgeon to be in attendance in the operating room at the time of induction. Operating mom nurses frequently have questions which only the operating surgeon can resolve, especially in this era of nurse shortage and increasingly frequent nurse turnover. A lack of surgical nursing experience is becoming the rule rather than the exception, and inexperienced nurses need instruction.

House staff or surgical assistants also frequently need direction in making immediate presurgical preparations. Patient positioning, preparations for interoperative X-rays, the set-up and checking of specialized, highly technical equipment, and other similar arrangements can all be expedited by the special attention of the operating surgeon, and he/she should be there to give it.

Finally, and most importantly, the issue of patient safety demands the presence of the surgeon, especially in those environments where housestaff Eire not present. Airway management during induction of anesthesia often requires a second informed and experienced participant. If cricothyrotomy is needed, I’ll pick a surgeon to help me rather than a nurse every time. In those rare episodes of cardiac arrest during inductions, and these do occur, a surgeon is a blessed help in providing the patient the best chance for a good outcome.

The patient trusts his well-being to us when he enters our operating room. As caring physicians, we own him an obligation to provide him with our best efforts. Our best effort am not forthcoming from the coffee lounge, nor from the locker room, nor even from the scrub sink. The surgeon belongs by his patient’s side during one of the most hazardous periods of the surgical experience during the induction of anesthesia.

Edward A. Brunner, M.D., Ph.D. Echenhoff Professor and Chairman Department of Anesthesia Northwestern University

But, on the other hand.

No … unless the operation is expected to start immediately after induction, such as a bronchoscopy, or the patient is afflicted with a true life-threatening emergency when everything is being done simultaneously. The surgeon otherwise will waste a lot of time while venous and arterial lines are placed, endotracheal intubation is accomplished, monitors are placed and checked, catheters am passed, and so on. In cases of regional anesthesia or the initial placement of continuous epidural catheters for postoperative analgesia, the wait can be even longer.

The modern anesthesiologist is fully trained to handle any cardiovascular or respiratory problem associated with the induction of either general or regional anesthesia. The insertion of new and more complex monitoring devices and fines can take a significant amount of tune and the surgeons’ physical presence is simply a waste of his time as well as a potential source of harassment to his anesthesiologist colleague. The surgeon is best out of the operating room at that time scrubbing up, making phone calls or even reading.

On the other hand, the surgeon should not be “off campus” or an inordinate time or distance away. At our hospital, the Department of Surgery constructed a surgical library of generous size and comfort, immediately adjacent to the operating room, which is newly-stocked with current medical and musical text books and journals. Waiting time of the surgeon and his assistants can thereby be put to good use. When the patient is property anesthetized, then the surgeon can position the patient and begin the work at hand, and his physical presence in the operating room at the time of anesthetic induction is not necessary.

Willard A. Fry, M.D. Professor of Clinical Safety Northwestern University Medical School Senior Attending Surgeon Evanston (IL) Hospital