Where Do You Draw the Line?

Margaret D. Franchi, CRNA, MS

Letter to the Editor:

To the Editor:

After reading Dr. Lee’s “Letter to the Editor” in the APSF Newsletter, I felt compelled to write one myself. A few years ago I made a presentation at one of our departmental Morbidity & Mortality meetings regarding “Where Do You Draw the Line?” Dr. Lee’s letter also addresses this issue. Too many times the focus is not on the patient and his or her welfare, but instead on whether we are on time with the schedule or whether we can set a new record for turnover time between cases. While performing an anesthetic in a timely fashion is important, I do not feel this should be the focus. No one wants to cancel a case because of last minute findings, but many elective cases are still being done without appropriate test results or actually listening to breath sounds. Obviously, we get away with these transgressions, but luck is not always on our side. Trying to proceed with an anesthetic after treating the patient as if they were one of your own family members (there truly is more thoroughness) is the best way to keep our priorities in line. Pressure to produce from the facility and pressure to keep the surgeon happy should not be the guidelines!

Working in a facility that trains anesthesiology residents and CRNA students adds extra pressure to our need for proper priorities. We are setting the example for these future providers. We have the duty to teach them what proper vigilance and practice entails. As anesthesia providers, our main focus needs to be on doing our best to prevent any harm to the patient. This basic premise actually encompasses a lot. It covers everything from thorough room set-up and anesthesia machine check to essential pre-anesthetic assessment and documentation. Also covered is the need for paying attention to the fundamental tasks of proper positioning, organization, and monitoring. This premise includes keeping the patient properly anesthetized, whatever technique is chosen, from local/sedation, regional, general anesthesia (mask, LMA, or ETT) and the many ranges in between. Vigilant patient monitoring throughout every case is essential. This can only be accomplished if our focus is on “doing our best to prevent any harm to the patient.”

Also included in this focus would be regularly reviewing new research and keeping ourselves up to date. I wish I could honestly say that all anesthesia providers have the required focus and priority setting, but unfortunately, many have allowed their “line” to slip beyond what is safe and actually acceptable.

Perhaps, my getting up on my soapbox will be seen as too idealistic, but I sincerely hope not. I hope each of us re-evaluates where we draw our own lines and attempts to relocate them to a safer practice.

Margaret D. Franchi, CRNA, MS
Royal Oak, MI