To the Editor
The issue of an anesthesiologist’s physical presence, or lack of, in the radiology suite raised by Timothy W. Martin is addressed by the ASA’s “Standard for Basic Monitoring”1 both in general and in particular. In the introductory paragraph, the Standard states that, “In certain rare or unusual circumstances, 1) some of these methods of monitoring may be clinically impractical,” and “Brief interruptions of continual monitoring may be unavoidable.” The Standard then goes on to describe the actions that the anesthesiologist should take under these circumstances. This statement should in general adequately cover the situation of brief absences during radiation treatment.
Under STANDARD I (Presence in the room)2 in the section described as OBJECTIVE, the second sentence specifically addresses radiation therapy and what actions should be taken if the anesthesia personnel have to leave the room because of the radiation hazard to personnel. This covers the situation in radiation therapy in particular.
However, several other issues are also raised. The first is that state law, if it forbids the presence of any other person in the room during radiation therapy as it does in Maine,3 will pre-empt any standard from a professional organization. A standard only represents an opinion, albeit one with the force of a national organization, and thus is a lower ranking document. If you disagree with state law, you can work to change it, but until that time you must work with the tools that are available to make the procedure as safe as possible within those constraints. If you feel that the situation is so unsafe that therapy should not be administered, it should be because of other correctable issues, not just because of a standard that is in conflict with state law.
These 2 elements show that the ASA Standards for Basic Monitoring do not need revision as they already adequately cover the situation.
Bernard C. DeLeo, MD,4 raises a similar issue concerning the presence of anesthesia personnel present in the scanner during MRIs. He feels that anesthesia personnel should be actually in the magnet room, though an informal survey at a refresher course suggests that 50% of the attendees feel this is not required.4
Timothy Martin’s letter raises the question, is the important issue actually being “in the room” or being able “to see” the patient, even if it is through shielded glass or via a video camera? Ironically, when a pediatric patient is in the scanner tube, all bundled up, you cannot see anything of the patient except the anesthesia reservoir bag (if the patient has a “contained” airway and is breathing spontaneously) even if you are in the in the magnet. You are totally dependent on your monitoring for any quantitative information on what is happening.
Perhaps the requirement for a physical presence (apart from the need to be there to actually administer the anesthesia) arose in part because in the early days of anesthesia, monitoring was pretty much limited to what you could hear, sees, feel, or smell. With traditional monitors and other newer modalities of monitoring, all amenable to signal processing, physical proximity to the patient may be less of an issue (assuming the ability to intervene at short notice) provided that you can still “see.” Mark Warner, MD, during the Rovenstine Lecture at the 2005 ASA in Atlanta challenged the audience to look for new ways to deliver anesthesia care. Maine Medical Center (Portland, Maine) has just introduced E-Care whereby an intensive care physician is available for consultation for patients at a remote location.
Could the same scenario potentially happen for anesthesia, with the clinician being present electronically rather than physically?
Richard M. Flowerdew, MB
- Martin TW. Radiation therapy removes anesthesia provider from the treatment room. APSF Newsletter 2005;20:57.
- Standards for Basic Anesthetic Monitoring. Park Ridge, IL: American Society of Anesthesiologists, Inc., 1986, Amended 2005. Available at: http://www.asahq.org/ publicationsAndServices/standards/02.pdf. Accessed March 16, 2006.
- Therapeutic Radiation Machines. 10-144A CMR 220 (August 1, 2001). Part X. Section 6R(6). Available at: http://mainegov-images.informe.org/dhhs/eng/ rad/pdffiles/rules/Part%20X%20Therapeutic%20Radiation%20Machines.pdf. Accessed March 17, 2006.
- DeLeo BC. MRI monitoring done with in room. APSF Newsletter 2005;20:57.