Who’s Putting You Under?

Few patients preparing for surgery ever bother to ask who will be putting them under. They typically focus on finding a good surgeon--or the right hospital or clinic--giving little thought to the person who will be giving them anesthesia.

While it’s important to pick the right doctor and setting for your surgery, it’s your anesthesia provider who is entrusted with keeping you alive.

Sure, anesthesia today is safer than it was years ago. Mortality rates have dropped from about 1 in 10,000 in the early 1980s to an estimated 1 in 250,000, according to several studies.

Yet even with better monitors and medications, it’s tricky work to alter consciousness and temporarily paralyze a patient.

A host of things can go wrong: sudden and potentially dangerous changes in blood pressure, severe drug reactions, excessive bleeding or a halt in breathing that requires resuscitation. And in rare instances, patients can die.

Dr. Ronald Katz, a USC anesthesiologist who has taught anesthesia for years, warns students there are unknowns each time a patient is put under: How will the drugs work together? How will the patient’s body react to them? “All drugs are dangerous,” he notes, “and anesthesia consists of multiple drugs.”

While potential risks are known, there is a lack of good safety data to pinpoint the reasons why problems occur. “It’s very hard to differentiate when somebody has a complication. Is it the anesthesia? Is it the surgery? Is it patient disease?” said Dr. Lee A. Fleisher, an anesthesiologist at Johns Hopkins Hospital in Baltimore.

Fleisher and researchers in Great Britain have estimated that anesthesia is directly responsible for 1 in 183,000 deaths during surgery. Though that indicates that anesthesia is relatively safe, Fleisher believes that where you have your surgery influences safety. He and colleagues reviewed 170,000 Medicare patients who underwent outpatient surgery. They found that the safest place was a free-standing surgery center, while the least safe was a doctor’s office.

Advances in anesthesia have made it possible to move more surgeries--often cosmetic procedures--out of hospitals and into doctors’ offices. At the same time, there is growing concern about the unregulated nature of surgery done in doctors’ offices, where there is scant oversight by medical officials and few government reporting requirements.

Some highly publicized cases, including five deaths of patients undergoing elective surgeries in Florida, have heightened concern and prompted debate in medical circles. Some of the Florida deaths have been linked to anesthesia problems, prompting that state’s medical board in August to impose a three-month moratorium on general anesthesia in outpatient offices.

The ban has prompted concern that some cosmetic surgeons are circumventing the restrictions by relying more heavily on deeper intravenous sedation, which may pose a greater risk of serious breathing complications.

“We’re getting reports all over the state” of such incidents, said Dr. David Mackey, an anesthesiologist with the Mayo Clinic in Jacksonville, Fla.

Only a few other states, including California, Texas, New Jersey and Rhode Island, regulate office-based surgery. Ohio prohibits general anesthesia in offices.

Given the risks, it pays to be informed. Patients should ask about the credentials and experience of whoever will handle anesthesia and know how a facility is equipped for emergencies.

That knowledge is becoming increasingly important as insurers push for delivery of more medical care outside the hospital in less expensive outpatient clinics and doctors trying to protect their income operate in the more lucrative arenas of the ambulatory surgical center or private office--further from peer review.

Most consumers are unaware that medical doctors with special training in anesthesiology aren’t the only health professionals allowed to put patients under.

Nurse-anesthetists have been around for more than a century. About 27,000 practice today. They are specially trained to deliver and monitor the medications that provide sedation and pain relief.

A certified registered nurse-anesthetist completes two to three years of graduate training following a bachelor’s degree and at least one year of critical care nursing. Three of the nation’s 90 accredited nurse-anesthesia programs are in California: at the Samuel Merritt College in Oakland, at Cal State Fullerton and at USC. The programs include advanced anatomy, physiology, pharmacology and anesthesia practice, and about 1,000 hours of hands-on experience.

Hospitals dictate the scope of nurse-anesthetists’ practices. The nurse-anesthetist may have an independent practice, working directly with a physician or surgeon; may be teamed with an anesthesiologist in the operating room or work under the supervision of an anesthesiologist rotating among several operating rooms. In California, nurse-anesthetists are routinely used, for example, in Kaiser Permanente hospitals, in Veterans Affairs facilities and in private surgery centers.

The nation’s approximately 30,000 anesthesiologists are medical doctors who completed four-year anesthesiology residencies in addition to their other medical education. Unlike nurse-anesthetists, medical doctors are qualified to diagnose and to prescribe. Some hospitals exclusively use anesthesiologists; most use nurse-anesthetists as well.

Whether nurses should be able to oversee anesthesiology procedures has become a national issue. The White House is considering a federal proposal that would revise Medicare reimbursement rules so that hospital nurse-anesthetists could work without a doctor’s supervision. While nurses contend that they are qualified to function alone, anesthesiologists argue for oversight by doctors, especially of the sickest patients.

Anesthesiologists also question whether nurses have the fortitude to challenge a doctor and halt surgery if they perceive danger to the patient. Several nurse-anesthetists interviewed recounted incidents where they risked a doctor’s wrath by stopping anesthesia upon discovering an undiagnosed illness or drug abuse.

At Kaiser Permanente in Southern California, doctors report a positive experience with its program of having physicians team up with nurse-anesthetists. Dr. Jim DeFontes, anesthesia coordinating chief for the Southern California Permanente Medical Group, said such team care provides much-needed backup during surgery. It is also economical, he said, because it averts expensive mistakes, while offering the patient “a safer experience, more likely a better outcome and hopefully better service.”

While DeFontes respects nurse-anesthesists, he cautions that “we need to be careful how far we expand scopes of practice and allow people to practice unsupervised. There’s a lot of financial pressure to do that.”

Anesthesia professionals stand together in warning that doctors, dentists and podiatrists should provide nothing but the simplest sedation or local anesthetics unless an anesthesia professional is present.

Several cases underscore their position: A La Jolla dermatologist miscalculated the dose of an anesthetic during liposuction, and the patient died. A Pasadena dentist has been charged with 64 counts of child endangerment and unprofessional conduct involving 40 children. He allegedly oversedated the youngsters, one of whom was left with brain damage, with oral chloral hydrate. A judge is set to rule next month in the case. Children have died from poorly monitored use of the same drug prescribed by radiologists to keep them still during magnetic resonance imaging.

“We’re having little children with a cavity dying,” said Ceil Vercellino, 41, of Agoura Hills, a former president of the California Assn. of Nurse Anesthetists. “Bring in a nurse-anesthestist or an anesthesiologist so you know how much of the drug is being given, how long it’s going to act.”

Although it is generally considered best medical practice to have separate medical professionals handling the anesthesia and the surgery, doctors who are not anesthesiologists can supervise nurse-anesthetists during procedures. In actual practice, however, nurse-anesthetists often work on their own unless the surgeon is called in during an emergency. Dr. Jon A. Perlman, a Beverly Hills plastic surgeon who operates at a surgery center, says his nurse-anesthetists are “so professional and they’re so skilled in doing anesthesia that in reality, I’m not giving much supervision.”

When he operates, crash carts and crash medications are within reach. In addition, he and his nurse-anesthetists are trained in advanced cardiac life support and the surgery center has a standing arrangement to transfer patients in emergencies to Cedars-Sinai Medical Center.

The best patient protection involves finding a good facility and experienced anesthesia provider, because, as spokesman Phil Weintraub of the American Society of Anesthesiologists, put it: “Even under the best of circumstances, no one can predict how each patient will react.”