Monday, July 30, 2012

Losing The Art Of Anesthesia

Recently I was doing some minor cases at the ambulatory center. One of the cases required that the patient be intubated for general anesthesia. When I told the OR staff about my anesthetic plan, the circulator kindly asked me if I wanted the video laryngoscope. I looked at him quizzically. "Why would I need to use video? The patient has a perfectly normal airway." He replied that many of my colleagues now use the video laryngoscope exclusively to intubate all their patients. Really? I was quite surprised by that information. Have anesthesiologists become so dependent on technology that something as basic as intubation skills have degenerated to the point we need electronic assistance to do the job?

For decades we anesthesiologists have been using advances in computers and monitoring to exponentially improve patient safety. I can't imagine doing anesthesia today without the automated sphygmomanometer, real time pulse ox readings, and capnography. Thankfully, the days of looking at a patient's skin color to determine adequate oxygenation are long gone. But has the use of video laryngoscopy made us lose confidence in this fundamental anesthesia skill? I've seen some anesthesia residents who don't even want to learn how to use a regular laryngoscope. All they want is the video scope, as if every facility they'll ever work in will automatically have one sitting in the corner for their convenience.

Another gadget that has almost reached ubiquity in the operating room is the ultrasound. I was preparing to perform an interscalene block for a shoulder case. Our anesthesia tech asked me if he should go get the SonoSite for the procedure. Again, I was surprised by the question. I don't do regional blocks that often but I felt confident enough in my abilities to do it with traditional anatomic landmarks and the nerve stimulator for guidance. The case went off without a hitch. However some of my colleagues who have had extra regional training almost always use the ultrasound to do their blocks. Am I missing the boat by continuing my ludditian (ludditic?) behavior?

Other procedures that I've been asked if I needed ultrasound guidance include central line placement and even an arterial line placement. The fear of a pneumothorax complication with central lines is so great now that our hospital mandates the use of ultrasound when placing the line. While I can see how the use of the ultrasound will increase the accuracy and safety of line placements, I don't want what I saw happen to one of my attendings happen to me.

During residency, we had an attending who was trained in central line placement only with ultrasound guidance. One day our machine broke and he had to teach the residents how to do the procedure without one. He didn't know how to use the classic technique of inserting the needle at the apex of the sternocleidomastoid muscle while pointing towards the ipsilateral nipple. Instead he kept pointing the needle perpendicular to the neck as if he was still using an ultrasound. Needless to say his technique didn't work. He stabbed the carotid artery a couple of times and we had to cancel the operation, much to the patient's and surgeon's chagrin. Since that traumatic experience, I have vowed not to tie my skills to the availability of an electronic crutch. It may be a losing battle but I think it is something we should all be practicing.

Sure it's more fun to play with the latest electronic gadgets. Who wants to learn the multiplication table from flash cards when it's so much more fun to do the same thing on an iPad? But we should never allow ourselves to forget how to perform fundamental anesthesia skills simply because it's more entertaining to watch yourself doing it on a little screen.


  1. I love these posts -- so informative, and near and dear to my heart. Do you ever use ultrasound for an arterial line?

  2. I am often staggered by the dependence that many have on technology, but I temper this with the thought that many attendings "knew the patient was oxygenated", or "knew the BP was OK" There is little doubt that these tools make the procedure safer the real question is are we now at the point of diminishing returns, and the personal satisfaction at mastering a difficult task.

  3. I've never done an ultrasound guided a-line placement. I scoffed the first time the tech offered me the ultrasound to put one in. But I did the same when they asked me if I wanted to use one for a central line. Now it is a requirement here. So never say never.

  4. If you absolutely can't place a radial a-line bilaterally, do you go to brachial, or use ultrasound? Just curious on how things are done in private practice (2nd year resident)