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WHO WILL BE PROVIDING ANESTHESIA CARE 10 YEARS FROM NOW?

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Author: Richard Novak, MD
THE ANESTHESIA CONSULTANT

Imagine this: It’s the year 2034. You’re diagnosed with gallstones and you need to have your gallbladder removed. This will require an operating room staffed with a surgeon, a nurse, a scrub technician, and an anesthesia professional. If the current trend of inadequate numbers of anesthesia clinicians in the United States is not reversed, this insufficient supply will be a major problem. Non-emergency surgery may be delayed for days, weeks, or longer.

The August 2024 issue of our specialty’s primary journal, Anesthesiology, included the landmark paper Closing the chasm: Understanding and addressing the anesthesia workforce supply and demand imbalance. This publication described the imbalance in the supply and demand of the anesthesia workforce since the COVID pandemic. Post-COVID we’ve seen a marked rise in the demand for anesthesia care, which has outstripped the supply of anesthesia clinicians. This shortage has hampered the ability of healthcare systems to provide surgical services. Before COVID, 35% of facilities reported an anesthesia staffing shortage. Two years after the pandemic, 78% of facilities reported an anesthesia staffing shortage.

In a professional labor market such as anesthesia providers, the supply of qualified clinicians cannot increase fast enough to ease the pressures resulting from a markedly increasing demand. The regulation of the number of MD residency and CRNA training positions, and the duration of time required to train new professionals, impede the ability to rapidly increase the supply of clinicians entering the workforce.

Specific trends have led to the anesthesia workforce supply–demand relationship. Per the Anesthesiology article, these trends include a) an aging patient population, b) an evolution of surgical procedures and procedural areas, c) the number of anesthesia providers entering the workforce, and d) the changing generational preferences and attitudes of these providers.

ANESTHESIA WORKFORCE BALANCE: INCREASED DEMANDS VS DECREASED SUPPLY OF PROVIDERS

Let’s examine how the Anesthesiology article described each of these trends:

An Aging Population

In 2023, more than 58 million Americans were 65 years of age or older (17.3% of the population). In 2050, there will be 90 million Americans 65 years of age or older.  Older patients have more medical problems, require a disproportionately increased number of surgeries, and are more susceptible to medical complications.

Evolution of Procedures and Procedural Areas

Procedures that used to be hospital-based have increasingly moved into outpatient settings and physician’s offices. This trend toward minimally invasive surgery has led to older and sicker patients who were at too high a risk for open procedures, to now be eligible for new noninvasive procedures. Noninvasive surgical procedures in hospitals, such as trans catheterization heart valve replacements, are often done outside a traditional operating room, which spreads out the anesthesia workforce and leads to an increased demand in remote non–operating room settings. This leads to lateral spread of anesthesia providers and scheduling challenges.

The Current Anesthesia Workforce in the United States

The Center for Medicare and Medicaid Services lists 97,000 anesthesia professionals in the United States who have billed Medicare in the last 6 to 12 months. The Center for Anesthesia Workforce Studies estimates that current clinically active anesthesia professionals are made up of 43,500 anesthesiologists, 50,000 nurse anesthetists, and 3,200 anesthesiologist assistants. They also estimate 5,200 anesthesia professionals entered the workforce from training programs in 2023: 1,900 anesthesiologists, 3,000 nurse anesthetists, and 300 anesthesiologist assistants. They estimate 4,800 anesthesia professionals left the workforce in 2022, including 2,500 anesthesiologists, 2,200 nurse anesthetists, and 65 anesthesiologist assistants. This represents a small net increase (400 professionals) in workforce supply, but this quantity is insufficient to keep up with the increase in demand. The net decrease in MD anesthesiologists was 2500 – 1900 = 600.

The Automation of Low-value Tasks

In the future, the delivery of anesthesia is expected to become more automated.  Command centers will likely allow professionals to supervise an increased number of locations safely in the operating room. Anesthesiologists currently spend a significant amount of time working with electronic medical record (EMR) entries, and the advent of the EMR has been linked to burnout. Artificial intelligence technology and automation of the EMR present potential opportunities to relieve clinicians from repetitive tasks.

Augmenting Anesthesia Clinical and Technical Skills

Published data shows artificial intelligence and closed-loop systems have the potential to simplify aspects of maintenance anesthesia care. Robotic models exist for fully automated anesthetic delivery, computer-controlled general anesthesia level, computer-controlled hemodynamic management, and computer-controlled sedation. These robotic systems are not likely to replace anesthesia professionals, but may increase the efficiency and safety of our practice and increase the ability to simultaneously supervise multiple anesthetizing locations in a safe manner. It’s speculated that mechanical robotic anesthesia advances, such as robot-assisted tracheal intubation and robot-assisted ultrasound-guided nerve blocks, may someday decrease anesthesia manpower needs.

The Invisible Hand of Economics: How Financial Reimbursement Affects Anesthesia Staffing

Abysmally low Medicare payments for anesthesia professionals affect the marketplace. The Medicare anesthesia physician fee schedule has not kept up with cost-of-living adjustments over the last twenty years. The current Medicare anesthesia conversion factor is less than 30% of the commercial conversion factor. Imagine this occurred in your workplace: that on some days you worked for the government, and you were paid only 30 percent of your usual income for your effort. What effect would this have? More likely than not you would seek an alternative career.

Potential Solutions:

The Anesthesiology article proposes the following solutions to the anesthesia labor supply–demand imbalance:

  1. Increase the pipeline. “Consideration should be given on a federal level to increasing the number of federally funded graduate medical education slots and to increasing training capacity through academic–community partnerships.” Strategies include increasing the number of positions in existing residencies, establishing new residency programs, shortening the duration of anesthesia training, and recruiting anesthesiologists from other countries. Increasing the number of anesthesiology professionals will be a slow process, due to the time required to train them, and will not quickly overcome the workforce imbalance. This approach also presents the risk of creating an oversupply of anesthesiology clinicians over the long term.
  1. Facilitate retention of anesthesia professionals. “The factors that affect retention include initiatives to address burnout, harassment, incivility, and violence; an inclusive culture; flexible scheduling; and transition to retirement that keep physicians in the workforce.”
  1. Improve capacity through innovations in practice. “These include models for the more efficient delivery of moderate sedation in non–operating room settings and acuity or risk-based models that may allow for greater physician supervision ratios in low-acuity settings.”
  1. Leverage technology. “Technology holds the promise to automate low-value tasks, increase the ability to supervise safely, and augment clinical skills.”
  1. Address financial constraints“. . . including deficiencies in Medicare payment for anesthesiologist services.”

My comments:

As a hybrid private-practice/academic clinician who has practiced anesthesiology since the 1980s, I’d make the following observations on the current supply-demand imbalance in my field and the worries about the future:

  1. Anesthesiology continues to be a popular residency choice among medical students, and was the 7th highest specialty in number of applicants in 2019. Because of the low supply of anesthesiologists, an abundance of job opportunities awaits graduates of anesthesia residencies.
  2. It’s a fact that there will be an inadequate number of anesthesia professionals (MDs, CRNAs, and AAs) in the foreseeable future. While we wait for an eventual increased output from training programs, some facilities will indeed be understaffed, particularly facilities which offer low reimbursement. There will be delays and some rationing of surgical procedures. Consolidation of surgery locations from understaffed rural facilities to urban/suburban hospitals and surgery centers is likely.
  3. Enticing anesthesia professionals to prolong their careers, i.e. not retire early, will require anti-burnout measures at the workplace.
  4. Enticing anesthesia professionals to prolong their careers, i.e. not retire early, will require Medicare to increase reimbursement from the current 30 cents on the dollar compared to the commercial rates. Aging anesthesiologists will prefer to go fishing than do difficult geriatric anesthetics for discount wages.
  5. Artificial intelligence and robotics will reduce the number of anesthesiologists required to manage a suite of operating rooms. Look forward to a time when AI modules provide routine medical care while fewer physicians oversee the process. (see my novel Doctor Vita for a vision of this future.)
  6. It’s unlikely that robots will replace the manual skills of anesthesia professionals (e.g. managing airways, placing breathing tubes, intravascular catheters, and pain blocks). The hands of an anesthesiologist cannot be replaced by machinery.
  7. There will be a market for quality medical care. Just as some wealthy individuals currently purchase the services of a concierge internist, wealthy patients will likely spend money to purchase access to better surgical care.
  8. Could Medicare for all, or universal healthcare, resolve the injustice of inadequate health care access? If there are an inadequate number of medical professionals, the vision of universal access to medical care for all will not become reality.
  9. Increasing the number of anesthesiologists, CRNAs, and anesthesiologist assistants is the obvious key to the supply-demand imbalance. I believe medical leadership will focus on this solution, but as described above, this solution will take years to change the marketplace.

Anesthesiologists, CRNAs sound alarm on provider shortages: What 5 organizations are saying

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Author: Francesca Mathewes
Becker’s ASC Review

A 2024 Medicus white paper forecasts a shortage of 6,300 anesthesiologists by 2036, and anesthesia provider organizations are speaking out on the impact on the physicians and practitioners they represent.

Here are what CRNA, anesthesiologist and certified anesthesiologist assistant organizations told Becker’s about the ongoing shortage. These groups represent both national and state-specific perspectives on the shortage:

Janet Setnor, MSN, CRNA. President of American Association of Nurse Anesthesiology: 

There are two immediate needs for the healthcare workforce. First, increasing the pipeline of providers to meet the increasing demand. Secondly, removing barriers to ensure that the current workforce allows all providers to work to the top of their education and training, allowing for the most efficient use of all healthcare providers. Budget cuts in nursing programs have led to qualified applicants being turned away, while there is set to be a nearly 50% increase in demand for advanced practice nurses in the coming decade. Investment in nursing education and the workforce pipeline is critical. Last year over 55,000 qualified applicants were turned away from nursing programs due to insufficient clinical placement sites, faculty, preceptors, and classroom space, as well as budget cuts. This constrains the pipeline of registered nurses, even as the Bureau of Labor Statistics cites an estimated 40% growth in the demand for advanced practice registered nurses, including CRNAs in the coming years. Outdated federal programs such as Medicare and the Veterans Health Administration continue to place unnecessary barriers to care between patients and providers, such as CRNAs. Removing these burdensome barriers will allow both CRNAs and physician anesthesiologists to provide direct patient care, increasing the utilization of the current workforce and making it more efficient and cost effective.

Ronald Harter, MD. President of the American Society of Anesthesiologists: Building on two recent workforce summits held by ASA, member experts drafted a special article in Anesthesiology, the peer-reviewed journal of ASA, published in 2024: “Closing the Chasm: Understanding and Addressing the Anesthesia Workforce Supply and Demand Imbalance.” The paper outlines emerging trends affecting the unfolding staffing crisis, with a view toward developing much needed sustainable short- and long-term solutions. As surgery and other procedures resumed after the height of the COVID-19 pandemic, surging demand placed additional stress on “an already fragile workforce.” Thepercentage of facilities reporting an anesthesia staffing shortage increased from 35% inearly 2020 before the pandemic to 78% in late 2022. That creates “a dangerous spiral of work intensity and stress, unsustainable workloads, and retirements from clinical practice,” according to lead author Amr Abouleish, M.D, and professor of anesthesiology at the University of Texas Medical Branch [in] Galveston. While staffing shortages are seen throughout the health care system, “reliable anesthesia staffing is essential to provide high-quality, safe and timely procedural care, which is a major financial driver for health systems.”

Antonio Hernandez Conte, MD. Former President of the California Society of Anesthesiologists: For anesthesiologists, the practitioner shortage is resulting in highly demanding and unsustainable work schedules. Anesthesiologists are under pressure to take more calls, work after hours and cover long shifts, and cannot take time off. This undermines quality of life for the specialty, which in turn makes it hard to attract the next generation of anesthesiologists. The healthcare workforce is aging right now as well, which means that something needs to change in order to ensure there are enough anesthesia practitioners available in the next 10 to 20 years.

Tennessee Association of Nurse Anesthetists: Oftentimes, the tendency is to look at staffing shortages in anesthesia or other specialties simply in terms of supply and demand. Essentially, are there enough providers to meet the demand for care? However, it’s often not as simple as that, because the factors that contribute to shortages may be as vast, complex and constantly evolving as the healthcare landscape itself. Factors such as workforce pipeline, retention and recruitment, burnout and fatigue, aging population of both patients and providers, barriers to practice, workplace environment and geography can all play a role in staffing shortages. But one of the most significant factors behind perceived provider shortages is staffing model efficiencies: In other words, are resources being allocated efficiently and used effectively? In Tennessee, we are focused on finding solutions, but that requires asking the right questions, assessing our state’s specific needs and looking at data, not anecdotes.

Kelli Ray, CAA. President of the Tennessee Academy of Anesthesiologist Assistants: We are facing an unprecedented shortage of anesthesia providers in Tennessee  and across the country. Many factors play into this demand, such as an aging patient population, growth in the number of non-surgical procedures requiring anesthesia, an increase in the number of outpatient surgery centers and a decrease in post-COVID medical providers. An online search for open CRNA positions in Tennessee currently results in almost 300 job listings. Oftentimes, these positions are being filled by traveling CRNA providers from out of state and come at a costly price.

SPIRO ROBOTICS: THE FUTURE OF DIFFICULT INTUBATION MANAGEMENT

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Author: Richard Novak, MD
THE ANESTHESIA CONSULTANT

I’ve seen the future of difficult intubation management, and I’ve held that future in my hands. The Spiro Robotics device—a combination video laryngoscope and fiberoptic endoscope in one unit—is a marked advance in anesthesiology, as well as a harbinger of how Artificial Intelligence can one day make difficult endotracheal intubation easier for all clinicians.

Disclosure: I have no financial interest or ownership stake in Spiro Robotics. I’m writing this review to inform anesthesia providers and laypersons regarding developments in the field of anesthesiology.

Vladimir Nekhendzy, Clinical Professor of Anesthesiology and Otolaryngology, Stanford University School of Medicine, and Past President of the Society for Head and Neck Anesthesia, is the inventor of the Spiro device. In Dr. Nekhendzy’s words, “Spiro-VISTA (Video Intubation System for Total Access) combines the power of video laryngoscopy, flexible endoscopy, and robotic precision into one handheld, easy-to-use device, setting a new standard for difficult airway management.”

The advantage of using a Glidescope plus a fiberoptic scope at the same time was demonstrated by Mazzarini et al in the 2019 Anesthesia and Analgesia publication Effect of Dynamic Versus Stylet-Guided Intubation on First-Attempt Success in Difficult Airways Undergoing Glidescope Laryngoscopy: A Randomized Controlled Trial. One hundred sixty adult patients with predicted difficult airways were randomly assigned to a conventional Glidescope intubation or a combined Glidescope + fiberscope intubation. The first-attempt intubation success was higher in the Glidescope + fiberscope group than in the standard Glidescope group (91% vs 67%; P = .0012). The median time to successful tracheal intubation was shorter in the Glidescope + fiberscope group than in the standard Glidescope group (50 vs 64 seconds; P = .035), and the airway injury rate was lower in the Glidescope + fiberscope group than in the standard Glidescope group (1% vs 11%; P = .035).

To date the Spiro device has been tested with a 100% success rate in intubating the trachea in 70+ cadavers in less than one minute per case. The device will now undergo a phase of safety and efficacy testing on difficult intubation human subjects, in its path toward expected eventual FDA approval.

THE DEVICE:

The heart of the Spiro device is the robotic base:

Spiro Robotics base unit

 

Two disposables attach to the base unit. The first disposable attachment contains the joystick and control buttons, and resembles the clear sleeve one slides over a video laryngoscope:

Disposable sleeve including joystick and buttons

The second disposable attachment contains the fiberoptic scope and clips on to the robotic base via two blue clamps.

Disposable fiberoptic laryngoscope attachment

The completed device, with both disposables attached, looks like this:

 

The next step involves threading the fiberoptic laryngoscope (FOL) through the lumen of an endotracheal tube (ETT), and sliding that FOL-ETT assembly into the channel of the Spiro device.

Complete Spiro unit with the fiberoptic laryngoscope threaded through an endotracheal tube, which is fitted into a grove on the Spiro device

 

The sleeve disposable contains a joystick and the control buttons, which the operator moves with his/her left thumb. Depressing the joystick moves the FOL distally, out of the tip of the ETT. Once the tip of the FOL is extended into the airway, the operator manipulates the direction of the FOL tip by maneuvering the joystick.

HOW TO USE THE DEVICE:

When the operator attaches the robotic base to the monitor, two images appear on the video screen which is attached to a wheeled base much like a Glidescope stand. The left half of the video screen shows the image from the Spiro video endoscope camera, and the right half of the video screen shows the image from the camera at the tip of the fiberoptic laryngoscope.

Initially the operator retracts the fiberoptic laryngoscope tip so that it is approximately 10 millimeters short of the beveled tip of the endotracheal tube. The Spiro device is then inserted into the patient’s mouth in the same manner that a videolaryngoscope is inserted.

The left half of the video screen will show the inside of the patient’s mouth, and the operator advances the device until the epiglottis is visualized. The operator then presses down on the joystick button until the FOL extends out from the endotracheal tube. The operator then maneuvers the joystick to direct the FOL tip under the epiglottis until the larynx is visualized. The operator once again pushes down on the joystick button, which advances the FOL into the trachea. At this point the operator manually advances the endotracheal tube over the FOL into the lumen of the trachea, and withdraws the FOL from the tube. The cuff of the endotracheal tube is then inflated. After 10–15 minutes of practicing with the Spiro device, I was able to easily utilize the technology and intubate the trachea of a difficult airway mannequin in less than 40 seconds.

I see the Spiro device as a definite advance over videolaryngoscopy alone, because it equips you with not just a videolaryngoscope, but also a fiberoptic laryngoscope aimed directly at the epiglottis and larynx. Spiro’s technology is backed by seven patents, including 1) dual cameras, 2) disposable controls, and 3) Al use in intubation.

ARTIFICIAL INTELLIGENCE:

A fascinating feature of the Spiro device is the potential of Artificial Intelligence/machine learning with this invention. In a demonstration of future AI capacity, the Spiro device was inserted into the mannequin’s airway and then the software for AI intubation was activated. The software controlled the motion of the tip of the FOL. Based on the digital images of the airway from the tip of the FOL, the device guided the FOL around the epiglottis and into the trachea without any input from the operator. This technology, once it’s perfected and approved for use in humans, will do what I once thought was all but impossible—it enables a device to intubate the trachea without any anesthesiologist input. AI may likely replace medical professionals in the interpretation of digital images in specialties such as pathology, dermatology, and radiology, but I never imagined AI replacing an anesthesiologist’s ability to intubate the trachea. Because Spiro’s AI software can reduce endotracheal intubation to the interpretation of digital images, it can make endotracheal intubation possible without an MD. I’ve written about robotics in anesthesia in a previous column.  Academics have previously invented an impractical robot to place an endotracheal tube, and have invented a robot that can perform regional blocks, but the previous inventions showed little promise for widespread application.

America is currently faced with a significant shortage of anesthesiology providers, which is projected to become an even bigger problem in the future. Closed-loop devices exist which can infuse maintenance doses of propofol and remifentanil without anesthesiologist input, with the rate of the infusions guided by a bispectral (BIS) monitor of EEG (electroencephalography) activity, but there has been little progress in machines to replace an anesthesiologist’s hands. With a bit of science fiction imagination, one can imagine a solitary attending anesthesiologist manning multiple operating rooms via a panel of video monitors, with each general anesthetic beginning with airway management by the Spiro placement of an endotracheal tube, and then AI technology controlling the depth of anesthesia by feedback loops gained from BIS-monitoring of a patient’s electroencephalogram (EEG) score.

Sound unbelievable? The tech advances of the past thirty years would have sounded unbelievable to an individual in 1994, but the advances arrived, and progress will continue.

THE MARKET:

How big is the market for the Spiro device? In a video featuring Spiro CEO Dimitri Sokolovd, he quotes the number of expected and unexpected difficult intubations as 6 million per year in American operating rooms, emergency rooms, and intensive care units. Each difficult intubation runs the risk of complications, including at the worst, anoxic brain damage, when an airway management is botched and oxygenation is lost for over five minutes. The current standard of care for difficult intubation is videolaryngoscopy. Videolaryngoscopy is not foolproof and can be unsuccessful.

The ASA Difficult Airway Algorithm contains instructions for a surgical airway (cricothyrotomy) should laryngoscopy be unsuccessful. No anesthesiologist wants to resort to cricothyrotomy to save a patient’s life. The need for a technology superior to videolaryngoscopy is real.

Each difficult intubation currently costs a hospital more than $14,000.  A 2021 study in ClinicoEconomics and Outcomes Research highlighted the significant costs associated with difficult intubation patients. This was a retrospective observational cohort study, conducted using three years of data (2016–2018) from more than 600 hospitals in the United States. The study compared the difficult intubation (DI) group to the non-DI group, and discovered that for the DI group the hospital cost was $14,468 more, and the length of hospital stay was 3.8 days longer than for the non-DI group. Use of the Spiro device is touted to pay for itself, as the increased cost for complications of difficult intubation is reduced or eliminated. What are the costs of the Spiro technology? While still investigational, the Spiro Robotics base unit, including the video screen, are expected to sell for $15,000. The two disposables, including the videolaryngoscope sleeve, the joystick and buttons, and the fiberoptic laryngoscope, will likely sell for about $350 per case. A hospital is likely to own a small number of base units, from one to three, which would be made available in the operating rooms suites, the emergency room, and the intensive care units. The total costs of using Spiro would depend on the utilization of the disposables for single patient use.

MY COMMENTS:

As a hybrid private practice/academic clinician who has practiced anesthesiology since the 1980s, I’ll make the following observations on the Spiro Robotics product I was allowed to demo:

  1. When faced with a difficult intubation in the future, would an anesthesia professional choose to use a videolaryngoscope device alone, or a videolaryngoscope + fiberoptic laryngoscope combined device, i.e. the Spiro device? After having my hands on the Spiro Robotics device, I would rather have the extra technology of the FOL in my hands when faced with a difficult airway, particularly if it was an emergency setting in which the time of adequate oxygenation to the brain was waning.
  2. What will be the marketplace utilization of videolaryngoscopy vs Spiro? The acquisition costs of a Spiro unit versus a Glidescope are not significantly different. The costs of the disposables are higher with a Spiro unit, because the disposables include a joystick controller and a fiberoptic laryngoscope.This increased cost may drive practitioners to use a Glidescope first, instead of the Spiro, for all but the most difficult airways, with Spiro available as backup. It’s possible that using videolaryngoscopy alone instead of Spiro for the first look on a difficult intubation patient will be unwise. If the delay in utilization of the Spiro device leads to anoxic brain damage, death, and/or a massive lawsuit, the medical center administration and the practitioner will wish they had not pinched pennies and had used the Spiro first.
  3. In the future the AI aspect of the Spiro unit may be the slickest airway management imaginable. Can the AI version of Spiro be used by lesser trained professionals to intubate the trachea, making the undersupply of anesthesia providers less of a crisis? Time will tell.

World Kindness Day 2024: Let’s Make Kindness Contagious

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Authors: Eileen Kodack, DO et al 
ASA Monitor October 2024, Vol. 88, 13–14.

“It takes courage to be kind.”

–Maya Angelou

Medicine is a noble field in which physicians selflessly and tirelessly dedicate their lives to patient care. In today’s health care landscape, however, there are increasing reports of workplace harassment and violence as well as burnout and mental health disorders among medical professionals. Perioperative teams are especially at risk due to their daily high-intensity interactions. How do we support each other when we are all under siege from overwhelming patient volumes, health care systems, insurance companies, and colleagues? The solution is not simple; it requires a systemic, collaborative approach. We can all start by doing one thing: being kind. Challenging workplace factors can be adjusted, even if slightly, to have a potentially big impact on the mental health of all health care workers.

Burnout is an occupational phenomenon, defined as emotional exhaustion, depersonalization, and a low sense of personal accomplishment. Afonso et al. first discussed the burnout phenomenon in anesthesiologists in March 2020, and it has only been exacerbated by the COVID pandemic (Anesthesiology 2004;140:38-51). Workplace factors include working greater than 40 hours per week, staffing shortages, and not feeling supported at work. Additional factors include not feeling supported outside of work and caregiving responsibilities.

In terms of dealing with burnout, organizations may differ with regard to staffing ratios and how administrations can better support employees. Additionally, each of us has our own unique situation when it comes to out-of-hospital responsibilities. Many of the factors are out of our control. We do, however, have the power to support one another in the workplace. When toxicity is infectious, make kindness contagious.

The phenomenon known as TED Talks was based on the concept of making ideas go viral. “You don’t need to be big and powerful; you just need to be infectious,” says Chris Anderson, the curator of TED Talks, in his compelling lecture titled “It’s Time for Infectious Generosity. Here’s How” (Anesthesiology 2021;134:683-96). He describes the belief that generosity has the power to spread like wildfire, igniting positive change and fostering a sense of interconnectedness among individuals. Anderson posits that generosity has the potential to create a ripple effect, inspiring others to pay it forward and perpetuating a cycle of kindness.

So, how do we initiate, integrate, and promote this idea in health care? Anderson suggests three essentials for contagious kindness: authentic human emotion, creativity, and courage (Figure 1). Positive emotions such as joy, empathy, and fulfillment can be evoked with the simplest acts, leading to a heightened sense of emotional well-being for both the giver and the receiver, fostering and enriching deeper connections. Innovative thinking and creative problem-solving lead to the discovery of new ways to make a meaningful impact and serve as catalysts for transformative acts of generosity. Lastly, it takes courage to open oneself to uncertainty and risk.

Figure 1

Figure 1

Under the leadership of Keith Lewis, MD, our department at Rutgers-Robert Wood Johnson Medical School has been on a mission to promote a healthy workplace culture. The “Kindness” campaign has included distribution of KIND® bars and “‘Bee’ Kind” pins as well as the creation of patient-centric initiatives and promotion of wellness events. The perioperative staff also participate in KindORSM training to highlight small acts of kindness that make a difference to patients, such as holding their hand, giving them a warm blanket, engaging in conversation with them, cleaning blood off their bodies before emergence, etc. (Figure 2). Our institution has adopted celebrating World Kindness Day on November 13 (asamonitor.pub/3ynBXoU). This systemwide event gives pause to each person, from medical student to executive to house staff to custodial staff – we all have the capacity to empathize with our fellow colleagues.

Figure 2

Figure 2

Kindness also has physiological effects on the people performing the acts, often leaving the performer with a feeling of happiness. When people are kind to one another, the human brain releases dopamine, serotonin, and even oxytocin. Dopamine activates the pleasure/reward center in our brains and is known as the “feel good” hormone. Dr. Waguih William IsHak, a professor of psychiatry at Cedars-Sinai, says that studies have linked random acts of kindness to dopamine release, which can give people a sense of euphoria or “helper’s high” (The Case for Kindness. 2022). Acts of kindness, no matter how small, release serotonin. Serotonin is known to improve one’s mood and make people happy, and it can even reduce anxiety and stress. Oxytocin contributes to feelings of respect and positive regard toward others. The release of serotonin and oxytocin together can actually improve one’s mental health (asamonitor.pub/3LNFK1R).

There is also a link between kindness and employee happiness. Studies have shown that kindness at work is a bigger predictor of happiness than income, feeling valued is one of the biggest contributors to workplace happiness, and doing purposeful work is directly linked to levels of happiness at work. Promoting kindness at work can help companies improve bottom-line results while also creating happier, more fulfilling work environments.

Embedding kindness into organizations has key benefits. People in leadership positions are being watched by all the staff, and how these leaders act in the workplace influences how others act (asamonitor.pub/3SvXCSA). A ripple effect can be seen as regular acts of kindness are performed. If you start your meetings with something positive and kind, the people in those meetings are more likely to continue to be positive and kind. People will work harder and be more engaged if they feel seen, heard, and valued (asamonitor.pub/3SvXCSA). Promoting kindness in the workplace leads to more productive employees who are committed not only to their jobs but also to the organizations where they work.

“Studies have shown that kindness at work is a bigger predictor of happiness than income, feeling valued is one of the biggest contributors to workplace happiness, and doing purposeful work is directly linked to levels of happiness at work.”

As World Kindness Day approaches, let’s keep in mind that although we may not have control over several variables in the health care system, we do have the power to be kind to each other. We propose a three-step process for initiating kindness in the workplace: Compassion, Patience, and Respect (CPR). Compassion understands, Patience listens, and Respect acknowledges the worth in every being. Together, they can resuscitate the spirit of empathy, nurturing a workplace where kindness flourishes once more (Figure 3).

Figure 3

Figure 3

Gastric Volume and Diabetes: Comment

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Author: Raghuraman M. Sethuraman, M.D.
Anesthesiology November 2024, Vol. 141, 1025.

I read the research article on the assessment of gastric volume in fasting patients with or without diabetes and the accompanying editorial with profound interest. I congratulate Perlas et al. for this path-breaking study and greatly value the editorial providing further insights on this interesting topic. I wish to present my reflections specifically on the design of the study.

The noninferiority trial is typically performed to assess whether a new treatment can offer improved safety or rather fewer unwanted effects, convenience, or reduced cost when compared to an established treatment.  However, the current study only assessed the impact of fasting in two different populations (persons with or without diabetes) and no intervention was performed.  Furthermore, the statistical analysis should compare the CI’s distribution with a designated noninferiority margin (delta), and null effect preferably with a diagram depicting all of them. More particularly, the planning focusing on these points should happen during the design stage itself. Perlas et al. did not mention these points in the trial registration. Indeed, they stated the type of study as an “Observational” one. Notably, the statement “This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines” reinforces that the type of this study is only “observational” and it is hard to fit it with a “noninferiority study.”

A Great Anesthesiologist Opportunity in Gadsden AL

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We are seeking a dedicated anesthesia care team to join our new anesthesia care team contract at Riverview Regional Medical Center.  Gadsden is a town of over 100,000 people that is located 1 hour from Birmingham AL and 2 hours from Atlanta GA.

Position Highlights:

  • Anesthesiologist call is 1:3
  • Competitive salary of $500,000 plus benefits.
  • 8 weeks of vacation.

Interested? Please contact me at 660-596-2224 or drrob@anesthesiaexperts.com if you or anyone you know would like to apply.

Note: Agencies, please do not contact us as we do not use your service

Discover The Best Anesthesiologist Opportunity in New Mexico

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We are seeking a dedicated anesthesiologist to join our all-anesthesiologist group. Our team will consist of 4 full-time providers and 1 for vacation relief, managing 3 operating rooms.

Position Highlights:

  • Zero call for 3 weeks, followed by 1 week of call without daytime work only call after 7 PM therefore you may not work the entire week.
  • Competitive salary of $500,000 plus benefits.
  • 8 weeks of vacation.

This is the best job on GasWork #370670

Interested? Please contact me at 660-596-2224 or drrob@anesthesiaexperts.com if you or anyone you know would like to apply.

Note: Agencies, please do not contact us as we do not use your service

Catheter-related internal jugular vein thrombosis in neonates and long-term consequences

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 Authors: Ling Xiong, M.D. et al 
Anesthesiology October 2024. doi:
Background

The incidence of central venous catheter-related thrombosis and the long-term effects of thrombosis on catheterized veins in neonates is unknown. We therefore determined the incidence of central venous thrombosis, identified associated risk factors, and evaluated outcomes at 6 months.

Methods

We enrolled neonates aged less than 28 days scheduled for major intestinal or cardiac surgery whom we expected to require central venous catheters for at least 48 hours. Catheter size, insertion method, and puncture site were determined by the attending anesthesiologist. The duration of catheterization was also determined by clinical need. Central venous thrombi were diagnosed by color Doppler ultrasound imaging within 48 hours after catheter removal; results were not shared with clinicians. Ultrasound examinations were repeated 1, 3, and 6 months after discharge.

Results

We enrolled 188 neonates over 2 years. The median duration of catheter insertion was 12 days. 128 (68%) of the neonates had central venous thrombi at the catheter site, all of which were asymptomatic. Among patients with thrombi, 29 (23%) had complete vessel occlusion and 5 (4%) had venous stenosis at 6 months after discharge. Thrombi therefore spontaneously resolved by 6 months in 73% of the neonates. CVC/vein diameter ratio, duration of catheterization, and catheter dysfunction were independent risk factors for vessel thrombus. Complete vessel occlusion was most common in patients whose thrombus occupied more than 58% of the vessel at the initial assessment.

Conclusions

Covert central venous thrombosis is frequent in neonates who have central venous catheters, and complications are most common in patients who have large intravascular thrombi. Neonates with large intravascular thrombi should be followed, and considered for anticoagulation.

APSF Announces Development of Third Technology Education Initiative (TEI) Course: Manual External Defibrillation, Cardioversion, and Pacing (MEDCP)

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Authors: Yuki Kuruma, MD et al 
Anesthesia Safety Patient Foundation Volume 39, No. 3
Figure 1: Interactive MED Simulation created for TEI 3.

Figure 1: Interactive MED Simulation created for TEI 3.

You are taking care of a 64-year-old male undergoing an above-the-knee amputation under general anesthesia. Despite a stable intraoperative course, his heart rhythm suddenly changes to atrial fibrillation with a rapid ventricular response in the 170s. With the change in rhythm, his systolic blood pressure is in the 60s and oxygen saturation is decreasing. You call for help, notify the team, and the operating room nurse brings in the crash cart with the manual external defibrillator. You know that a cardioversion is indicated, and time is of the essence to prevent further decompensation. Do you know where to place the pads? Which setting do you select for mode and at what energy? How will you know you are synchronized for the cardioversion to prevent an R-on-T phenomenon?

Perioperative cardiac arrests are rare and anesthesia professionals play a critical role in timely diagnosis and providing life-saving treatment.1 An essential skill is the ability to promptly apply and manage the manual external defibrillator (MED). A MED is the device that in-hospital ACLS providers use to perform an indicated defibrillation, synchronized cardioversion, and/or transcutaneous pacing.2 Since the MED is rarely used, and there is considerable duress in the setting of a life-threatening cardiac event, human error, such as device mismanagement and delay to delivery of therapy, can lead to a failure to rescue.3-4

Many hospital systems have transitioned to online, E-Learning programs for Advanced Cardiovascular Life Support (ACLS) certification provided by the American Heart Association (AHA).5 ACLS providers must complete short, refresher sessions every three months instead of every two years.5 These online courses do not commonly include education on the use of a defibrillator so many providers no longer maintain or refresh their knowledge of this device. We need easily accessible learning opportunities to teach new providers how to use this device and to allow staff to maintain their knowledge so they are able to quickly and competently use the MED in a crisis.

To meet this educational need, the Anesthesia Patient Safety Foundation (APSF), in collaboration with the American Society of Anesthesiologists (ASA), is announcing the development of a third Technology Education Initiative (TEI) course entitled “Manual External Defibrillation, Cardioversion, and Pacing (MEDCP)”. Previous courses have been Low-Flow Anesthesia6 and Quantitative Neuromuscular Monitoring.7 These courses use guided interactive simulation to provide an active learning experience for the user to understand complex, technology-based concepts.

The MEDCP course will consist of seven different topics that cover the essentials of understanding and using a MED, each targeted to require about 15 minutes to complete. Like previous TEI courses, guided simulation is used to provide an interactive learning experience. While the topics are recommended to be done in sequence, they do not need to all be completed at the same time for a more convenient learning experience. Highlights of the course include:

Physics of Defibrillators: A brief explanation of the physics behind the device that will allow you to better understand the MED.

Defibrillator Waveforms: Visualize and practice delivering the different types of electricity waveforms emitted from commonly used defibrillators.

Defibrillator Pad (Electrode) Placement: Practice placing defibrillator pads on a simulated patient in the different anatomical locations, including anterior-posterior and anterior-lateral.

Defibrillation, Synchronized Cardioversion, and Transcutaneous Pacing: Use a simulated, generic MED (Figure 1) to practice performing the three main functions of the MED.

The course is projected to be completed in January 2025 and will be available online at the ASA website through the APSF web portal at https://www.apsf.org/TEI/. All the TEI courses are free and readily accessible. Any anesthesia professional or interested party can take any TEI course by creating a free guest account if not already an ASA member. Continuing medical education credits will be available for those that participate including patient safety and quality improvement.

We look forward to completing the course and hope it will be useful in better preparing you to manage a perioperative ACLS event.

REFERENCES

  1. Nunnally ME, O’Connor MF, Kordylewski H, et al. The incidence and risk factors for perioperative cardiac arrest observed in the national anesthesia clinical outcomes registry. Anesth Analg. 2015;120:364–370. PMID: 25390278
  2. Panchal AR, Bartos JA, Cabanas JG, et al. Part 3: Adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020;142:S366–S468. PMID: 33081529
  3. Cooper JB, Newbower RS, Kitz RJ. An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. Anesthesiology. 1984;60:3–42. PMID: 6691595
  4. Olympio, MA. Formal training and assessment before using advanced medical devices in the operating room. APSF Newsletter. 2007;22:63–68. https://www.apsf.org/article/formal-training-and-assessment-before-using-advanced-medical-devices-in-the-operating-room/. Accessed June 28, 2024.
  5. American Heart Association. RQI: Resuscitation Quality Program overview. https://cpr.heart.org/-/media/CPR-Files/Courses-and-Kits/RQI/RQI-Program-Overview.pdf. Accessed July 28, 2024.
  6. Anesthesia Patient Safety Foundation. Low-flow anesthesia. https://www.apsf.org/apsf-technology-education-initiative/low-flow-anesthesia/. Accessed July 28, 2024.
  7. Anesthesia Patient Safety Foundation. Quantitative neuromuscular monitoring. https://www.apsf.org/apsf-technology-education-initiative/quantitative-neuromuscular-monitoring/. Accessed July 28, 2024.

The Benefits of Aquatic Therapy for Pain Management

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Author: Dr Nikesh Seth

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For individuals living with chronic pain, finding effective, low-impact ways to manage symptoms is crucial. Aquatic therapy, a type of physical therapy performed in water, has become increasingly popular as a gentle and effective approach to pain management. This therapy utilizes the natural properties of water to create a safe and supportive environment for exercise, making it particularly beneficial for those with chronic pain conditions. In this blog, we’ll explore the many benefits of aquatic therapy and the science behind it and provide practical tips on how to get started.

What is Aquatic Therapy?

Aquatic therapy, also known as hydrotherapy or water therapy, involves performing exercises and therapeutic movements in a pool under the guidance of a trained therapist. The buoyancy, resistance, and warmth of the water create a unique environment that can help alleviate pain and improve physical function.

Aquatic therapy leverages three key principles of water:

  • Buoyancy reduces stress on joints and muscles by supporting a portion of the body’s weight, making it easier to move without pain.
  • Resistance from the water helps build strength while allowing for slow, controlled movements that reduce the risk of injury.
  • Hydrostatic Pressure enhances circulation and reduces swelling, contributing to pain relief and improved physical function.

This therapy is especially beneficial for individuals with conditions such as arthritis, fibromyalgia, chronic back pain, and those recovering from surgery. It’s also ideal for those who find traditional exercise difficult or painful.

The Science Behind Aquatic Therapy

Buoyancy and Reduced Impact

One of the primary benefits of aquatic therapy is the buoyancy provided by water. When you’re submerged, your body is partially supported by the water, reducing the amount of weight your joints and muscles need to bear. This decreased weight-bearing makes it easier and less painful to perform movements that might be difficult on land.

The buoyant environment also allows for greater freedom of movement, making it easier to improve flexibility and overall mobility. Because the impact on joints is minimized, individuals can engage in exercises that might otherwise cause discomfort.

Resistance and Strength Building

Water provides natural resistance that is both gentle and effective for building muscle strength. This resistance slows down movements, allowing for better control and reducing the risk of injury. Additionally, the intensity of the exercise can be easily adjusted by increasing the speed or changing the direction of movement.

Hydrostatic Pressure and Circulation

Hydrostatic pressure, the pressure exerted by water on the body, plays a crucial role in enhancing circulation. Improved blood flow is essential for reducing inflammation and promoting healing. Additionally, the gentle compression from water pressure helps reduce swelling, particularly in the legs and feet. This pressure also supports sore muscles, easing pain and promoting relaxation.

Benefits of Aquatic Therapy for Pain Management

Pain Reduction

One of the most immediate benefits of aquatic therapy is pain reduction. The warmth and buoyancy of water significantly reduce the perception of pain by relaxing tight muscles and increasing blood flow. Additionally, the sensory experience of being in water can distract from pain, providing both physical and mental relief.

Exercise in water, like on land, stimulates the release of endorphins—natural chemicals in the brain that promote a sense of well-being and act as natural painkillers. Regular participation in aquatic therapy can lead to improved mood and reduced stress, which further helps in managing chronic pain.

Enhanced Flexibility and Mobility

Water-based exercises are highly effective for improving joint flexibility and overall mobility. The resistance in water allows for controlled stretching and strengthening exercises, which can help increase the range of motion in affected joints without the pain associated with land-based exercises. The safe environment of water also reduces the risk of falls, making it easier for individuals with balance issues or severe pain to participate in regular exercise.

Stress Relief and Mental Wellbeing

The soothing properties of water can help relax both the mind and body. The warm water, combined with gentle movements, eases muscle tension and reduces stress and anxiety. Beyond the physical benefits, aquatic therapy also improves mental well-being by providing a calming environment that helps reduce symptoms of depression and anxiety. The combination of physical activity, social interaction, and the calming effects of water contribute to a better quality of life.

Types of Aquatic Therapy Exercises

Aquatic therapy includes a variety of exercises tailored to the individual’s needs and abilities. These exercises fall into several categories:

  1. Stretching and Flexibility Exercises: These involve gentle stretches and range-of-motion activities like leg lifts and arm circles, which improve flexibility without the discomfort often associated with stretching on land.
  2. Strengthening Exercises: Water walking or jogging provides an excellent workout for the muscles, particularly the legs and core, without the high impact of land-based exercises. Resistance exercises using water weights or resistance bands enhance the strength-building aspect of aquatic therapy.
  3. Aerobic and Cardiovascular Exercises: Water aerobics and swimming are great for improving cardiovascular health and building stamina. These exercises provide a full-body workout that engages almost every muscle group while being easy on the joints.

Getting Started with Aquatic Therapy

If you’re considering aquatic therapy, here are some tips on how to get started:

Consult with a Professional

Before beginning any new therapy, it’s important to consult with your healthcare provider or a physical therapist who specializes in aquatic therapy. They can help determine if aquatic therapy is appropriate for your condition and create a personalized treatment plan.

Choosing a Facility

Not all pools are suitable for aquatic therapy. Look for a facility with warm water pools, as warm water helps with muscle relaxation and pain relief. Ensure the facility has trained aquatic therapists who can guide you through the exercises safely and effectively.

What to Expect in a Session

A typical aquatic therapy session begins with a warm-up, followed by targeted exercises, and ends with a cool-down. Sessions usually last about 30 to 60 minutes, depending on your condition and goals. The therapist will guide you through each exercise, ensuring you’re performing them safely and effectively.

Safety Considerations

While aquatic therapy is generally safe, it’s important to follow these safety guidelines:

  • Wear Appropriate Swimwear: Comfortable and supportive swimwear is essential.
  • Stay Hydrated: Even though you’re in the water, it’s important to drink plenty of fluids.
  • Know Your Limits: Listen to your body and avoid pushing too hard. If something doesn’t feel right, stop and consult your therapist.
  • Progress Tracking and Adjustments: Keep track of your progress by journaling your sessions, noting any improvements in pain, mobility, or overall well-being. Periodically reassess your goals with your therapist to ensure you’re on the right track.

Key Takeaways

Aquatic therapy offers a unique and effective approach to managing chronic pain. The combination of buoyancy, resistance, and hydrostatic pressure in water provides a safe and supportive environment for exercise, making it easier to reduce pain, improve mobility, and enhance overall well-being. If you’re living with chronic pain, consider exploring aquatic therapy as part of your treatment plan. Always consult with your healthcare provider to ensure it’s the right option for you, and take the first step towards feeling better by finding a program near you. Remember, every journey towards pain management is personal, and with the right tools and support, you can make significant strides towards a better quality of life.

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