Mr. Frith,

It is sad that you have missed the entire point. It matters not whether you have an Anesthesiologist or a Nurse Anethetist(CRNA) providing anesthesia care. They do the exact same thing administer anesthesia. They are people who excell at working under 100% zero margin of error. However, they are human. As with everything in life there are tragic events...things that should have been identified, corrected and stopped. Unfortunately, we will all have to wait and see what the real facts were that allowed a very treatable condition take the life of this 18 year old. I will challenge you as well as your readers... make sure the person you choose and the place you choose are capable, quality people that can handle the emergencies. Do not be naive and think because you have a Anesthesiologist or you are at hospital your care is safe. Look beyond the titles and see what you have underneath. As for me, you would be the last lawyer I would ever choose to represent anyone. You did not know your facts and with your pen marred groups of people by your faulty opinions. Even still you fall into your own trap by your follow up retraction. Do better by your profession and represent the facts.

Sincerely

Dina

Mr. Frith:

Excellent response Dina! Way to go! As for you Mr. Frith, you are just another misinformed soul. Dina hit the nail on the head when she said that all anesthesia providers are human. We are all affected by stress, fatigue, emotion, and the effects of our personal lives. We also know and are expected to follow standards of care issued by our respective license boards and professional associations.
Why does the general public automatically assume that just because a "doctor" is on the case that they will get the best and "safest" care? The answer is that they are ignorant as to what goes on behind closed doors. Most providers whether MD-anesthesiologist-MD surgeon, CRNA-Certified Registered Nurse are excellent in what they do. But the quality of care is usually based on the caliber of the individual giving the care. I have seen many MD-anesthesiologist that I would not want caring for me. The majority of MDA's rarely "do anesthesia". For those that dont know-MDA's generally come in when the patient goes off to sleep-watches me push the drugs, put the tube in listen to breath sounds, and then they leave. They might drop in to say Hi at some point. I generally wake the patient up and take to the recovery room all while the MDA is sitting in the lounge watching his stocks or drinking coffee. No great medical miricle here folks. Lets face it, CERTIFIED REGISTERED NURSE ANESTHETISTS DO THE ANESTHESIA IN THIS COUNTRY. I am tired of everyone bashing my profession. MDA groups would love to replace CRNA's with their "anesthesiolgist assistants" What are those you ask? A person with NO healthcare experience prior to doing assistant training. That is what they are "assistants" NOT PROVIDERS. Doctors want control so they want "assistants" not other providers on a level playing field. Sorry but anesthsiologists are not miricle workers. Things would be much better in health care if MDs would come down off their throne and work as a team and not a dictator. Anesthesiologist=overpaid supervisor.

Mr. Firth,

A number of distinct and separate issues are raised by your blog. Directly addressing the subject of the article, the unfortunate death of a young girl who underwent outpatient surgery, caused by Malignant Hyperthermia (MH), your point that outpatient centers do not have the same resources to deal with emergencies as do hospitals is well taken. However, the majority of surgeries take place in outpatient surgery centers in this country and with an excellent safety record. Even if we decided that the monumental expense of building whole hospitals for thousands of daily outpatient surgeries, complete with emergency and critical care services (stretched to the breaking point in our existing facilities) translated into a statistical difference in morbidity and mortality (which we know it would not since the morbidity and mortality in outpatient centers is already lower than that of hospitals). Study after study...after study...over the last 2 decades has shown the incredible safety of outpatient surgery...including cosmetic surgery. Yes hospitals have far more emergency resources...because they have far more emergencies, far more often and few emergencies which occur in an outpatient center cannot be initially very adequately treated while EMS arrives and the patient transported to an ER..all per pre-established protocol. We are not talking about band-aids and tape as emergency equipment in an outpatient center either. Every center is required to maintain a list of sophisticated equipment and medication and the CRNA or MDA are qualified to administer identical emergency care. IDENTICAL...PERIOD.

As for Malignant Hyperthermia, no other anesthesia emergency has its own national hot line staffed 24 hours a day with hot line posters hanging on the wall at all anesthetizing locations in every single operating room in the country. Why? Because it is a rare, difficult to recognize early, yet requiring the earliest intervention to successfully treat, incredibly aggressive once symptoms are clear, frightening, very difficult to treat requiring large amounts of very expensive and dated medication (often hospitals share supplies), very deadly disease. It is the nightmare of all anesthesia providers. It is not called Malignant for nuthin'. Most might only see a single case their entire anesthesia career. I have seen three myself, but only because I practiced in a free standing trauma center where all of my patients were trauma patients (a major risk factor). Even in the very best trauma facility in the country, attuned to MH and with all the resources possible, not all survived.

Finally, your comment "For me, I want an anesthesiologist responding to my medical emergencies and not a nurse anesthetist" is certainly anyones right as an opinion (since we are not basing them on science). I wonder however, why the ~40,000+ nurse anesthetists in this country do not share the same view when entrusting the care of their children, mothers, grandparents, etc. to anesthesia professionals. Certainly they should have an unparalleled familiarity with anesthesia practice as it REALLY exists (who knows what, what is dangerous, etc.). Of course all 40,000 might be egomaniacs to the point of sacrificing the safety of their loved ones, criminally insane, sociopaths, or stupid (I can hear certain circles making smart comments). Or, because of the competitive application process requiring a grade point average similar to medical school, the intensity of the curriculum of schools of nurse anesthesia, they are likely none of these. They are most likely intelligent professionals who are proud of their 100+ year history of high quality care. We should listen to them, they might know something.
Personally I would want the most skilled anesthesia provider available. Unfortunately you cannot, and should not determine that from initials after a name. It is very hard to educate the public, legal profession, etc. on something that simply cannot be taught, but rather has to be experienced...and that something is the REAL practice of anesthesia, the REAL art behind the science which every OR nurse, a multitude of surgeons (and even anesthesiologists) will readily acclaim is practiced with excellence by the CRNA. I wish I could show the incredible about face done by anesthesiologists once there are no sound bites or news interviews where suddenly, in direct opposition to all the rhetoric, the CRNA next to them is deemed just as capable and sometimes more so in handling all aspects of anesthesia care....by the anesthesiologists themselves. In 20 years I have NEVER heard from an MD; "Hey, I should do that, after all we have different jobs and I am more qualified than you." I have frequently been called on for a particular skill I excel in, by an anesthesiologist, and likewise I have called an anesthesiologist or another CRNA when a difficult case/procedure is their specialty. THAT is the real story.

When are we going to admit that any surgical procedure that is unnecessary is a poor idea and the risk of death is not nil? An inverted nipple as a birth defect, really? Its no cleft palate. By the way, that can be 'fixed' under local.

The CRNA's I work with day in and day out are exceptional and I trust them with my patients completely. The problem of being in an office for cosmetic surgery, as we have seen here, is even the most skilled anesthesiologist (or CRNA) have limited help and it takes a number of people to get through an episode of MH. Although I agree with Mr. Frith about having an anesthesiologist take care of me, I would prefer to be in a hospital or ASC where I would have both working in the Care Team mode because together we are stronger than alone. We have different training that compliments each other and in an emergency the more help the better.

All deaths of this sort are tragic, and most of these comments are very pertinent. However, I take issue with the statement that "CRNA's do the anesthesia in this country". For 23 years I have practiced medicine in the operating room...sometimes supervising anesthetists, most often doing the cases myself. Some providers are more capable, some are less capable...most of us end up in work situations that are suited to our abilities. NO ONE commonly handles malignant hyperthermia so we would all be stressed to encounter this situation. Anesthesiologists and nurse anesthetists, however, do NOT have the same training....Medical school and residency can not be equated with nursing school and CRNA school...lots of commonalities, but distinct specialties. I know many very skilled surgical PA's, but most of the time I would like the surgeon doing the surgery.

Anesthesiologist direction and patient outcomes.Silber JH, Kennedy SK, Even-Shoshan O, Chen W, Koziol LF, Showan AM, Longnecker DE.
Center for Outcomes Research, the Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, PA 19104, USA. Silberj@Wharton.Upenn.Edu

BACKGROUND: Anesthesia services for surgical procedures may or may not be personally performed or medically directed by anesthesiologists. This study compares the outcomes of surgical patients whose anesthesia care was personally performed or medically directed by an anesthesiologist with the outcomes of patients whose anesthesia care was not personally performed or medically directed by an anesthesiologist. METHODS: Cases were defined as being either "directed" or "undirected," depending on the type of involvement of the anesthesiologist, as determined by Health Care Financing Administration billing records. Outcome rates were adjusted to account for severity of disease and other provider characteristics using logistic regression models that included 64 patient and 42 procedure covariates, plus an additional 11 hospital characteristics often associated with quality of care. Medicare claims records were analyzed for all elderly patients in Pennsylvania who underwent general surgical or orthopedic procedures between 1991-1994. The study involved 194,430 directed and 23,010 undirected patients among 245 hospitals. Outcomes studied included death rate within 30 days of admission, in-hospital complication rate, and the failure-to-rescue rate (defined as the rate of death after complications). RESULTS: Adjusted odds ratios for death and failure-to-rescue were greater when care was not directed by anesthesiologists (odds ratio for death = 1.08, P < 0.04; odds ratio for failure-to-rescue = 1.10, P < 0.01), whereas complications were not increased (odds ratio for complication = 1.00, P < 0.79). This corresponds to 2.5 excess deaths/1,000 patients and 6.9 excess failures-to-rescue (deaths) per 1,000 patients with complications. CONCLUSIONS: Both 30-day mortality rate and mortality rate after complications (failure-to-rescue) were lower when anesthesiologists directed anesthesia care. These results suggest that surgical outcomes in Medicare patients are associated with anesthesiologist direction, and may provide insight regarding potential approaches for improving surgical outcomes. (Key words: Anesthesiologists; anesthesia care team; quality of care; mortality; failure-to-rescue; complication; Medicare; general surgery; orthopedics.)

PMID: 10861159 [PubMed - indexed for MEDLINE]

The above listed abstract from Jeff Silber (a non-anesthesiologist) has more than a few flaws. One of the co-authors, Dr. David Longnecker, said the study does not explore the role of nurse anesthetists in anesthesia practice, nor does it compare anesthesiologists versus nurse
anesthetists. The abstract also admits it remains to be determined whether the findings were the result of a caregiver or a hospital effect. The death rates cited in the abstract are
100 times greater than the death rates reported in recent years.
It should be clear that this entire issue is about income and not outcomes.
Mr. Frith's is clearly not qualified to render anything other than personal opinion/anecdote on this matter.