Con: Cardiac Anesthesiologists Should Not Be the Intensivists of the Operating Room Daniel W. Johnson, MD,* and Edward A. Bittner, MD, PhD†
A
NESTHESIOLOGISTS can be challenged when caring for patients who are critically ill before surgery and by those who develop critical illness during a surgical procedure. The care of critically ill patients can be fundamentally different from the routine care rendered in the operating room. In the setting of a major intraoperative crisis such as cardiac arrest, massive unexpected hemorrhage, or hypoxemia refractory to aggressive therapies, the skill set of the operating room team can be pushed to the limit. Operating room crises require rapid, coordinated management in a stressful, time-critical setting, and successful resuscitation depends largely on clinicians’ retained knowledge and skill. Failure to adhere to critical steps in the management of such crises is common and may be hazardous to patients. A high-fidelity simulation study of ventricular fibrillation cardiac arrests in the operating room revealed that 61% of anesthesiologists demonstrated “major deviations” from advanced cardiac life support protocols.1 The availability of specialized teams and resources for support during management of crisis situations is essential and is the focus of ongoing investigations.2,3 Physicians with expertise in the care of critically ill patients and who regularly manage acute crisis situations must be available to provide consultation in the operating room when the need arises. With formal training and daily experience in managing critically ill patients, the fellowship-trained critical care anesthesiologist is the obvious choice to fulfill this role. Unfortunately, the specialty of critical care medicine is facing a staffing crisis.4–6 The growing shortage of intensivists and its implications for hospitalized Americans is well documented and remains an ongoing concern for hospitals, clinicians, and the federal government.6 The mismatch between intensivist supply and demand is expected to worsen as inpatient volume and acuity grow in concert with an aging and increasingly comorbid population.4 Faced with the mandate to provide care for their growing intensive care unit (ICU) populations, hospitals are innovating to offset this shortage through the use of telemedicine systems and alternative staffing models, which include expanding the roles of nurse practitioners and physician assistants in the ICU.7,8 In addition, there have been efforts to create new training and credentialing pathways for hospitalists and
From the *Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE; and †Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA. Address reprint requests to Edward A. Bittner, MD, PhD, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street WHT 437, Boston, MA 02114. E-mail: [email protected] © 2014 Elsevier Inc. All rights reserved. 1053-0770/2602-0034$36.00/0 http://dx.doi.org/10.1053/j.jvca.2014.03.019 Key words: intensivist, staffing model, critical care 1168
emergency medicine physicians to expand the intensivist pool.9,10 Strategies to leverage resources to match the increasing volume and acuity of patients in the operating room also are needed. Consequently, the argument that cardiac anesthesiologists should act as intensivists for the operating room, as posited by Shear and Greenberg, seems appealing.11 Cardiac anesthesiologists are skilled clinicians who possess the specialized expertise necessary to care for patients undergoing a wide variety of cardiac surgical procedures, including major valvular repairs, complex congenital heart surgery, multiorgan transplantation, ventricular assist device insertion, extracorporeal membrane oxygenation, and coronary bypass procedures. They are skilled in the use of electrical cardiac pacing, mechanical and pharmacologic support of the circulation, and transesophageal echocardiography. Critical care anesthesiologists often consult with cardiac anesthesiologists regarding the management of patients with complex hemodynamic disturbances, to discuss echocardiographic imaging and optimal pharmacologic and mechanical support strategies. But despite cardiac anesthesiologists’ specialized expertise in caring for patients with severe cardiovascular disease, there are limitations in the breadth of their critical care expertise. The field of critical care has made tremendous advances during the past 50 years. These advances have consequently led to increased subspecialization. On any given day, a critical care physician may be asked to assess, diagnose, and treat critically ill patients with both common and rare problems, many of which are not directly related to the cardiovascular system. Examples of these problems include the critically ill obstetric patient with eclampsia, the patient with septic shock-induced multi-organ failure, the patient with acute thermal injury, and the patient with traumatic brain injury. The broad-based and comprehensive nature of intensivists’ daily work and training make them the optimal consultants for the general anesthesiologist in the operating room. In addition, intensivists possess the skills to perform a myriad of diagnostic, monitoring, and therapeutic activities. Examples include, but are not limited to, management of intracranial hypertension; bronchoscopy; invasive and noninvasive hemodynamic and respiratory monitoring; management of renal replacement therapy; advanced management of and weaning from mechanical ventilation; percutaneous tracheostomy; tube thoracostomy; cardiopulmonary resuscitation; cardioversion and electrical cardiac pacing; mechanical and pharmacologic support of the circulation; parenteral and enteral nutrition; fluid, electrolyte, and acid-base support; management of extracorporeal membrane oxygenation; hyperbaric oxygen therapy; intra-aortic balloon counterpulsation; and analgesia and sedation for both acute and chronic pain. The daily variety of clinical activities performed by intensivists is perhaps unmatched by any other specialist in the hospital. Additionally, through their everyday practice, intensivists become skilled in rapidly mobilizing and coordinating the efforts of a wide variety of subspecialists to provide care for the
Journal of Cardiothoracic and Vascular Anesthesia, Vol 28, No 4 (August), 2014: pp 1168–1170
1169
PRO AND CON
critically ill patient. These include surgeons, medical consultants, radiologists, nurses, pharmacists, and respiratory therapists. When a complex patient is deteriorating in the operating room, the ability to rapidly assemble an effective team of experts is essential. Finally, there may come a time when continued care is futile and perhaps inappropriate. In such circumstances, the intensivist has the training and experience to discuss the humane and ethical withdrawal of aggressive medical care while continuing to provide comfort measures for the patient and emotional support for the family. In summary, the anesthesiologist-intensivist offers colleagues a “one-stop shop” for the sickest patients in the operating room. Anesthesiology residents are required to complete 4 months of ICU training, and fellows in cardiothoracic anesthesiology are required to complete an additional month of cardiac ICU training. While these rotations are integral parts of residency and fellowship, 5 months of critical care training are not adequate to prepare a physician for the breadth of practice required in critical care medicine. There is an ever-increasing amount of practice-altering literature emerging in critical care medicine. The cardiac anesthesiologist cannot be expected to keep up with the constant deluge of ICU literature any more than the critical care anesthesiologist can be expected to remain on top of the cardiac anesthesiology and surgery literature. Perhaps the single greatest benefit of subspecialization is the opportunity to stay up to date in a particular field of the medical literature so that optimal evidence-based practice might be implemented. Assigning a subspecialist role to a clinician without the needed specialty knowledge clearly undermines this benefit. How do we provide the needed resource of critical care expertise to the operating room? A first step is to call upon the intensivist who is staffing the ICU for an intraoperative consultation. Often the intensivist can temporarily step away from the ICU to go to the operating room. This is mutually beneficial, because the intensivist will often assume care of the critically ill patient postoperatively. Too often, however, this resource is underutilized. More generally, if we accept the data that there is a looming crisis in the workforce of available critical care physicians and that critical care specialization leads to improved patient outcome, then it is time to seriously and definitively address the problem. The challenge is not only how to leverage existing resources to provide the best care for our critically ill patients, but how to expand the resource pool of intensivists for the increasing number and acuity of surgical patients anticipated in the future. Although alternative staffing and delivery models utilizing advance practice providers are being implemented to extend care to the critically ill patient population, fellowshiptrained, board-certified intensivists will continue to be required.
Simple steps can be taken to increase the pool of critical care anesthesiologists. Medical schools and their associated departments of anesthesiology need to ensure that medical students have ample exposure to critical care anesthesiologists. In other words, the seed must be planted early. Many young people aspire to be physicians because they want to save lives, reverse critical illness, and relieve pain. What field fits these aspirations better than critical care anesthesiology? But in a country where too many people lack the knowledge that anesthesiologists are physicians, we also have far too few medical students who are aware of the subspecialty of critical care and the role of the anesthesiologist in it. How can we expect medical students to choose a field when they have no awareness of it until the fourth year of medical school or later? Providing third-year medical students with a rotation in critical care supervised by an anesthesiologist-intensivist likely would go a long way toward increasing interest in the specialty. In addition to increasing intensivist numbers from within our own specialty, it is essential that we support the efforts to expand the pool of intensivists more generally and foster greater collaboration between subspecialties. The American Board of Anesthesiology recently collaborated with the American Board of Emergency Medicine to create a formal pathway for emergency medicine physicians to become board certified in critical care after successful completion of an Anesthesiology Critical Care fellowship.12 This is an important step forward in expanding the pool of qualified physicians available to care for critically ill patients and could have a tangibly positive impact on the intraoperative availability of anesthesiologist-intensivists. Capitalizing on their specialized knowledge and skills, the cardiac anesthesiologist can serve as a valuable resource to the general operating room in providing care for critically ill patients with cardiovascular disturbances. In addition, the cardiac anesthesiologist can certainly serve as a “second set of skilled hands” when an intensivist is not immediately available. But the argument that cardiac anesthesiologists can adequately substitute for intensivists is no sounder than the argument that intensivists can substitute for cardiac anesthesiologists. Care of critically ill patients by physicians formally trained and experienced in critical care medicine should be available. This coverage should be provided until the patient is no longer critically ill. In the short term, we will have to develop novel ways of leveraging existing resources while long-term goals must focus on expanding the pool of physicians with expertise in critical care. The goal is not merely to “make do” with existing resources but rather an opportunity for our profession to rise to the occasion in achieving the overarching goals of assuring critical care for all.
REFERENCES 1. Kurrek MM, Devitt JH, Cohen M: Cardiac arrest in the OR: How are our ACLS skills? Can J Anaesth 45:130-132, 1998 2. Arriaga AF, Bader AM, Wong JM, et al: Simulation-based trial of surgical-crisis checklists. N Engl J Med 368:246-253, 2013 3. Al-Qahtani S, Al-Dorzi HM, Tamim HM, et al: Impact of an intensivist-led multidisciplinary extended rapid response team on hospitalwide cardiopulmonary arrests and mortality. Crit Care Med 41:506-517, 2013 4. U.S. Department of Health & Human Services, Health Resources and Services Administration: Report to Congress: The
critical care workforce: A study of the supply and demand for critical care physicians. Available at: http://bhpr.hrsa.gov/health workforce/reports/studycriticalcarephys.pdf. Accessed March 13, 2014. 5. Krell K: Critical care workforce. Crit Care Med 36: 1350-1353, 2008 6. Halpern NA, Pastores SM, Oropello JM, et al: Critical care medicine in the United States: Addressing the intensivist shortage and image of the specialty. Crit Care Med 41:2754-2761, 2013
1170
7. Garland A, Gershengorn HB: Staffing in ICUs: Physicians and alternative staffing models. Chest 143:214-221, 2013 8. Gershengorn HB, Johnson MP, Factor P: The use of nonphysician providers in adult intensive care units. Am J Respir Crit Care Med 185: 600-605, 2012 9. Siegal EM, Dressler DD, Dichter JR, et al: Training a hospitalist workforce to address the intensivist shortage in American hospitals: A position paper from the Society of Hospital Medicine and the Society of Critical Care Medicine. Crit Care Med 40: 1952-1956, 2012
JOHNSON AND BITTNER
10. Huang DT, Osborn TM, Gunnerson KJ, et al: Critical care medicine training and certification for emergency physicians. Crit Care Med 33:2104-2109, 2005 11. Shear T, Greenberg S: Pro: Cardiac anesthesiologists should be the intensivists of the operating room. J Cardiothorac Vasc Anesth 28: 1166-1167, 2014 12. American Board of Anesthesiology, American Board of Emergency Medicine: Anesthesiology Critical Care Medicine (ACCM) Eligibility Criteria for ABEM Diplomates. http://www.theaba.org/pdf/ ACCM-FAQs.pdf. Accessed March 13, 2013.
A
NESTHESIOLOGISTS can be challenged when caring for patients who are critically ill before surgery and by those who develop critical illness during a surgical procedure. The care of critically ill patients can be fundamentally different from the routine care rendered in the operating room. In the setting of a major intraoperative crisis such as cardiac arrest, massive unexpected hemorrhage, or hypoxemia refractory to aggressive therapies, the skill set of the operating room team can be pushed to the limit. Operating room crises require rapid, coordinated management in a stressful, time-critical setting, and successful resuscitation depends largely on clinicians’ retained knowledge and skill. Failure to adhere to critical steps in the management of such crises is common and may be hazardous to patients. A high-fidelity simulation study of ventricular fibrillation cardiac arrests in the operating room revealed that 61% of anesthesiologists demonstrated “major deviations” from advanced cardiac life support protocols.1 The availability of specialized teams and resources for support during management of crisis situations is essential and is the focus of ongoing investigations.2,3 Physicians with expertise in the care of critically ill patients and who regularly manage acute crisis situations must be available to provide consultation in the operating room when the need arises. With formal training and daily experience in managing critically ill patients, the fellowship-trained critical care anesthesiologist is the obvious choice to fulfill this role. Unfortunately, the specialty of critical care medicine is facing a staffing crisis.4–6 The growing shortage of intensivists and its implications for hospitalized Americans is well documented and remains an ongoing concern for hospitals, clinicians, and the federal government.6 The mismatch between intensivist supply and demand is expected to worsen as inpatient volume and acuity grow in concert with an aging and increasingly comorbid population.4 Faced with the mandate to provide care for their growing intensive care unit (ICU) populations, hospitals are innovating to offset this shortage through the use of telemedicine systems and alternative staffing models, which include expanding the roles of nurse practitioners and physician assistants in the ICU.7,8 In addition, there have been efforts to create new training and credentialing pathways for hospitalists and
From the *Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE; and †Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA. Address reprint requests to Edward A. Bittner, MD, PhD, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street WHT 437, Boston, MA 02114. E-mail: [email protected] © 2014 Elsevier Inc. All rights reserved. 1053-0770/2602-0034$36.00/0 http://dx.doi.org/10.1053/j.jvca.2014.03.019 Key words: intensivist, staffing model, critical care 1168
emergency medicine physicians to expand the intensivist pool.9,10 Strategies to leverage resources to match the increasing volume and acuity of patients in the operating room also are needed. Consequently, the argument that cardiac anesthesiologists should act as intensivists for the operating room, as posited by Shear and Greenberg, seems appealing.11 Cardiac anesthesiologists are skilled clinicians who possess the specialized expertise necessary to care for patients undergoing a wide variety of cardiac surgical procedures, including major valvular repairs, complex congenital heart surgery, multiorgan transplantation, ventricular assist device insertion, extracorporeal membrane oxygenation, and coronary bypass procedures. They are skilled in the use of electrical cardiac pacing, mechanical and pharmacologic support of the circulation, and transesophageal echocardiography. Critical care anesthesiologists often consult with cardiac anesthesiologists regarding the management of patients with complex hemodynamic disturbances, to discuss echocardiographic imaging and optimal pharmacologic and mechanical support strategies. But despite cardiac anesthesiologists’ specialized expertise in caring for patients with severe cardiovascular disease, there are limitations in the breadth of their critical care expertise. The field of critical care has made tremendous advances during the past 50 years. These advances have consequently led to increased subspecialization. On any given day, a critical care physician may be asked to assess, diagnose, and treat critically ill patients with both common and rare problems, many of which are not directly related to the cardiovascular system. Examples of these problems include the critically ill obstetric patient with eclampsia, the patient with septic shock-induced multi-organ failure, the patient with acute thermal injury, and the patient with traumatic brain injury. The broad-based and comprehensive nature of intensivists’ daily work and training make them the optimal consultants for the general anesthesiologist in the operating room. In addition, intensivists possess the skills to perform a myriad of diagnostic, monitoring, and therapeutic activities. Examples include, but are not limited to, management of intracranial hypertension; bronchoscopy; invasive and noninvasive hemodynamic and respiratory monitoring; management of renal replacement therapy; advanced management of and weaning from mechanical ventilation; percutaneous tracheostomy; tube thoracostomy; cardiopulmonary resuscitation; cardioversion and electrical cardiac pacing; mechanical and pharmacologic support of the circulation; parenteral and enteral nutrition; fluid, electrolyte, and acid-base support; management of extracorporeal membrane oxygenation; hyperbaric oxygen therapy; intra-aortic balloon counterpulsation; and analgesia and sedation for both acute and chronic pain. The daily variety of clinical activities performed by intensivists is perhaps unmatched by any other specialist in the hospital. Additionally, through their everyday practice, intensivists become skilled in rapidly mobilizing and coordinating the efforts of a wide variety of subspecialists to provide care for the
Journal of Cardiothoracic and Vascular Anesthesia, Vol 28, No 4 (August), 2014: pp 1168–1170
1169
PRO AND CON
critically ill patient. These include surgeons, medical consultants, radiologists, nurses, pharmacists, and respiratory therapists. When a complex patient is deteriorating in the operating room, the ability to rapidly assemble an effective team of experts is essential. Finally, there may come a time when continued care is futile and perhaps inappropriate. In such circumstances, the intensivist has the training and experience to discuss the humane and ethical withdrawal of aggressive medical care while continuing to provide comfort measures for the patient and emotional support for the family. In summary, the anesthesiologist-intensivist offers colleagues a “one-stop shop” for the sickest patients in the operating room. Anesthesiology residents are required to complete 4 months of ICU training, and fellows in cardiothoracic anesthesiology are required to complete an additional month of cardiac ICU training. While these rotations are integral parts of residency and fellowship, 5 months of critical care training are not adequate to prepare a physician for the breadth of practice required in critical care medicine. There is an ever-increasing amount of practice-altering literature emerging in critical care medicine. The cardiac anesthesiologist cannot be expected to keep up with the constant deluge of ICU literature any more than the critical care anesthesiologist can be expected to remain on top of the cardiac anesthesiology and surgery literature. Perhaps the single greatest benefit of subspecialization is the opportunity to stay up to date in a particular field of the medical literature so that optimal evidence-based practice might be implemented. Assigning a subspecialist role to a clinician without the needed specialty knowledge clearly undermines this benefit. How do we provide the needed resource of critical care expertise to the operating room? A first step is to call upon the intensivist who is staffing the ICU for an intraoperative consultation. Often the intensivist can temporarily step away from the ICU to go to the operating room. This is mutually beneficial, because the intensivist will often assume care of the critically ill patient postoperatively. Too often, however, this resource is underutilized. More generally, if we accept the data that there is a looming crisis in the workforce of available critical care physicians and that critical care specialization leads to improved patient outcome, then it is time to seriously and definitively address the problem. The challenge is not only how to leverage existing resources to provide the best care for our critically ill patients, but how to expand the resource pool of intensivists for the increasing number and acuity of surgical patients anticipated in the future. Although alternative staffing and delivery models utilizing advance practice providers are being implemented to extend care to the critically ill patient population, fellowshiptrained, board-certified intensivists will continue to be required.
Simple steps can be taken to increase the pool of critical care anesthesiologists. Medical schools and their associated departments of anesthesiology need to ensure that medical students have ample exposure to critical care anesthesiologists. In other words, the seed must be planted early. Many young people aspire to be physicians because they want to save lives, reverse critical illness, and relieve pain. What field fits these aspirations better than critical care anesthesiology? But in a country where too many people lack the knowledge that anesthesiologists are physicians, we also have far too few medical students who are aware of the subspecialty of critical care and the role of the anesthesiologist in it. How can we expect medical students to choose a field when they have no awareness of it until the fourth year of medical school or later? Providing third-year medical students with a rotation in critical care supervised by an anesthesiologist-intensivist likely would go a long way toward increasing interest in the specialty. In addition to increasing intensivist numbers from within our own specialty, it is essential that we support the efforts to expand the pool of intensivists more generally and foster greater collaboration between subspecialties. The American Board of Anesthesiology recently collaborated with the American Board of Emergency Medicine to create a formal pathway for emergency medicine physicians to become board certified in critical care after successful completion of an Anesthesiology Critical Care fellowship.12 This is an important step forward in expanding the pool of qualified physicians available to care for critically ill patients and could have a tangibly positive impact on the intraoperative availability of anesthesiologist-intensivists. Capitalizing on their specialized knowledge and skills, the cardiac anesthesiologist can serve as a valuable resource to the general operating room in providing care for critically ill patients with cardiovascular disturbances. In addition, the cardiac anesthesiologist can certainly serve as a “second set of skilled hands” when an intensivist is not immediately available. But the argument that cardiac anesthesiologists can adequately substitute for intensivists is no sounder than the argument that intensivists can substitute for cardiac anesthesiologists. Care of critically ill patients by physicians formally trained and experienced in critical care medicine should be available. This coverage should be provided until the patient is no longer critically ill. In the short term, we will have to develop novel ways of leveraging existing resources while long-term goals must focus on expanding the pool of physicians with expertise in critical care. The goal is not merely to “make do” with existing resources but rather an opportunity for our profession to rise to the occasion in achieving the overarching goals of assuring critical care for all.
REFERENCES 1. Kurrek MM, Devitt JH, Cohen M: Cardiac arrest in the OR: How are our ACLS skills? Can J Anaesth 45:130-132, 1998 2. Arriaga AF, Bader AM, Wong JM, et al: Simulation-based trial of surgical-crisis checklists. N Engl J Med 368:246-253, 2013 3. Al-Qahtani S, Al-Dorzi HM, Tamim HM, et al: Impact of an intensivist-led multidisciplinary extended rapid response team on hospitalwide cardiopulmonary arrests and mortality. Crit Care Med 41:506-517, 2013 4. U.S. Department of Health & Human Services, Health Resources and Services Administration: Report to Congress: The
critical care workforce: A study of the supply and demand for critical care physicians. Available at: http://bhpr.hrsa.gov/health workforce/reports/studycriticalcarephys.pdf. Accessed March 13, 2014. 5. Krell K: Critical care workforce. Crit Care Med 36: 1350-1353, 2008 6. Halpern NA, Pastores SM, Oropello JM, et al: Critical care medicine in the United States: Addressing the intensivist shortage and image of the specialty. Crit Care Med 41:2754-2761, 2013
1170
7. Garland A, Gershengorn HB: Staffing in ICUs: Physicians and alternative staffing models. Chest 143:214-221, 2013 8. Gershengorn HB, Johnson MP, Factor P: The use of nonphysician providers in adult intensive care units. Am J Respir Crit Care Med 185: 600-605, 2012 9. Siegal EM, Dressler DD, Dichter JR, et al: Training a hospitalist workforce to address the intensivist shortage in American hospitals: A position paper from the Society of Hospital Medicine and the Society of Critical Care Medicine. Crit Care Med 40: 1952-1956, 2012
JOHNSON AND BITTNER
10. Huang DT, Osborn TM, Gunnerson KJ, et al: Critical care medicine training and certification for emergency physicians. Crit Care Med 33:2104-2109, 2005 11. Shear T, Greenberg S: Pro: Cardiac anesthesiologists should be the intensivists of the operating room. J Cardiothorac Vasc Anesth 28: 1166-1167, 2014 12. American Board of Anesthesiology, American Board of Emergency Medicine: Anesthesiology Critical Care Medicine (ACCM) Eligibility Criteria for ABEM Diplomates. http://www.theaba.org/pdf/ ACCM-FAQs.pdf. Accessed March 13, 2013.
