Sir William Osler described imperturbability as “coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgement in moments of grave peril, immobility, impassiveness.” He declared the physician who is misfortunate enough to be without imperturbability, “who shows that he is flustered and flurried in ordinary emergencies, loses rapidly the confidence of his patients” (Aequanimitas: with other addresses to medical students, nurses and practitioners of medicine.1920).

The practice of anesthesiology is occasionally marked by the unexpected, such as hemorrhage, arrythmias, and embolic events. The startle response that occurs can result in the delay of appropriate action or the initiation of inappropriate action (asamonitor.pub/3YC78aP). Confusion can be compounded when users are not familiar with the function of the equipment they’re using or when it is poorly integrated with the user’s experience or expectations (asamonitor.pub/3LWu7pv; asamonitor.pub/3SDDf60).

The adaptive reaction to unplanned emergencies consists of the fight, flight, or freeze response. Hyperarousal can lead to tunnel vision, tunnel hearing, loss of accurate time perception, and regression to nonprofessional behaviors, such as yelling and panicking (Code Calm on the Streets. 2012). If this occurs, it inhibits the leader’s ability to manage the situation and impedes the psychological safety of the team, dissuading members from speaking up with ideas and suggestions (asamonitor.pub/3WToWwG). This behavior hinders the deliberative, creative, and collaborative approach required to successfully navigate the unexpected situation (Wiring the Winning Organization. 2023). Indeed, lack of imperturbability also rapidly loses the confidence of the team.

Actions that support imperturbability include:

• Preparation
  • Providing excellent care begins with taking care of ourselves. Anesthesia professionals who are hungry, dehydrated, tired, or otherwise unwell have decreased capacity to handle the unexpected (The Emergency Mind. 2021). ASA offers a number of resources: asahq.org/advocating-for-you/well-being.
  • Practice. The response to crisis events can be rehearsed with high-fidelity simulation, but case-based discussions and mental rehearsals are more readily available and quite effective (Acad Emerg Med 2007;14:130-7; asamonitor.pub/4fE6Shu). There is no substitute for familiarizing yourself with the function of the anesthesia equipment you use and the meanings of the various monitor warnings and alarms.
  • Plan for the unanticipated. Not every case will require multiple I.V.s, invasive monitoring, or blood products, but if you needed these suddenly in the middle of the case, what would your plan be to obtain them? Recognize that this might vary depending on the resources available at the time the case is occurring.
• Acute response
  • Control your breathing. Combat tactical breathing is frequently used by the military and athletes to mitigate hyperarousal, stimulate parasympathetic activity, and help regain focus (see Figure) (asamonitor.pub/46TH8tP).
  • Call for help. Assistance from others can introduce an “outside” view of the situation, often by those without personal involvement in the event; but their views, especially dissenting ones, need to be invited and welcomed (The Emergency Mind. 2021; ASA Monitor 2023;87:34).
  • Use cognitive aids, such as crisis manuals. They can be essential for remembering the steps and sequence of a task, but the user must already be skilled and experienced in the task itself (BMJ Qual Saf 2015;24:545-9).
• Recovery
  • One of the essential keys to maintaining imperturbability is adequate recovery (The Emergency Mind. 2021). After experiencing challenging circumstances, support needs to be readily available (Jt Comm J Qual Patient Saf 2010;36:233-40; ASA Monitor 2022;86:12; asamonitor.pub/3AeYuFf).

In addition to knowledge and experience in the field of anesthesiology, following the tips provided above can help the anesthesia professional achieve imperturbability when the unexpected happens.

Large hiatal hernias can have significant implications for perioperative management. The accompanying images display a large hiatal hernia compressing the heart (fig. 1A) and inferior vena cava (fig. 1B). Hiatal hernias are not uncommon, especially in elderly patients. Approximately 25% of people over the age of 50 yr have a hiatal hernia. 

Large hiatal hernias may present without gastroesophageal reflux disease and gastrointestinal obstruction symptoms, and as such may escape notice in a preoperative assessment. These patients are at increased risk of aspiration. Preinduction gastric tube insertion can help decompress the stomach, reducing the risk of aspiration, and improving ventilation. Additionally, rapid sequence induction or awake intubation, depending on the airway examination, is usually indicated.

Large hiatal hernias may also exhibit mass effect on the inferior vena cava and heart and cause increased intrathoracic pressures, especially with initiation of positive pressure ventilation  (see Video, Supplemental Digital Content, https://links.lww.com/ALN/D619, which demonstrates hiatal hernia compressing nearby organs). Compression of the inferior vena cava (fig. 1B) can impair venous return. Cardiac compression from a large hiatal hernia (fig. 1A), a so-called “tension gastrothorax,” may lead to arrhythmias, hemodynamic compromise, and even cardiac arrest.  As such, hiatal hernias should be considered as a possible cause of hemodynamic compromise, especially during anesthetic induction. Timely decompression of the dilated stomach often results in resolution of symptoms and return of hemodynamic stability. 

A 4-year-old male undergoing a procedure with an endotracheal tube who experienced a bronchospasm during induction is nonetheless planned for deep extubation at the end of the procedure in light of a reassuring airway and otherwise stable course.

After extubation, the patient coughed and appeared to bronchospasm with suctioning despite what appeared to be an adequate depth of anesthesia (3% sevoflurane with additional propofol and dexmedetomidine boluses just before extubation). The patient then became bradycardic, requiring CPR.

The patient recovered after two minutes of CPR and one dose of epinephrine, but had persistently low oxygen saturation for which the patient was reintubated. On auscultation, the patient had diminished bilateral breath sounds with expiratory wheezing.

The decision was made to keep the patient intubated and transport to the intensive care unit.

“Deep extubation” refers to the removal of the endotracheal tube while the patient is under general anesthesia with no response to stimuli and the absence of protective airway reflexes (Miller’s Anesthesia. 8^th ed, 2015). This contrasts with awake extubation, which is performed when the patient has recovered their airway reflexes and responds appropriately to verbal and physical stimuli. In practice, the definition and technique of deep extubation can vary widely.

The benefits of deep extubation are thought to include less straining, airway stimulation, hemodynamic changes, and patient movement on emergence, which can reduce tension on the surgical repair. Although no one surgery is an absolute indication for deep extubation, procedures such as open globe repair, intracranial surgery, head and neck surgery, and vascular surgeries may benefit from deep extubation.

Deep extubation can result in upper-airway obstruction, hypoventilation, laryngospasm, and aspiration. Contraindications to deep extubation include difficult mask ventilation, difficult intubation, high aspiration risk, and blood in the oropharynx (Anesthesiology Resident Manual of Procedures. 2021).

Although it is ideal for the patient to spontaneously breathe with adequate tidal volumes before extubation, this is not strictly necessary. The anesthesia practitioner may elect to extubate the patient deep and provide ventilatory support by mask until the patient’s respiratory drive returns.

Before deep extubation, care should be taken to ensure that the patient is at an adequate depth of anesthesia, which can be achieved with volatile and/or intravenous agents. Typically, a volatile MAC of 1.3 to 1.5 is targeted, although this may be lower depending on the presence of other intravenous agents such as opioids, propofol, or dexmedetomidine. A mixed volatile/intravenous anesthetic or total intravenous anesthetic are options as well. A small propofol bolus may temporarily deepen the patient to a safe level for deep extubation. Intravenous lidocaine may be given to further blunt airway reflexes.

There is an element of judgment when determining if the patient’s anesthetic depth is adequate for deep extubation. Sometimes, an extubation is claimed to be “deep” when, in fact, the patient is reactive to stimuli. For instance, one thought process is that the patient’s anesthetic depth needs to be lightened to restore spontaneous breathing, and that the endotracheal tube can always be removed safely without further assessment whenever spontaneous breathing resumes, even with a volatile MAC of 0.7 or lower. Although it is true that the volatile MAC value does not fully reflect a patient’s true depth of anesthesia, we urge caution in assuming that a patient who is just beginning to breathe spontaneously remains in a deep plane of anesthesia.

Deep extubation requires close supervision afterward, as the patient will not have a protected airway during stage 2 of anesthesia when airway irritability is at its peak. Irregular breathing, breath holding, and laryngospasm may occur. An anesthesia professional or a PACU nurse familiar with emergence should monitor the patient closely until they fully emerge from anesthesia. Although deep extubation is often believed to save time and improve OR throughput, increased efficiency alone should not be a reason for pursuing deep extubation.

In the case report above, the patient appeared to have a reactive airway on induction of anesthesia. Some would argue that this is grounds for an awake extubation. If the patient bronchospasms again or has another adverse event during emergence without a secure airway, it may be necessary to reintubate the patient. The lack of a secure airway may cause unnecessary respiratory complications.

On the other hand, deep extubation may help to reduce overall airway reactivity by removing an irritating foreign body from the trachea prior to emergence (You’re Wrong, I’m Right. 2016). Depending on the surgery, the severe coughing, straining, and hemodynamic changes during emergence with an endotracheal tube in place could lead to other complications. However, due to the patient’s known reactive airway, the practitioner should exercise particular caution in ensuring optimum conditions before deep extubation and should monitor the patient closely during emergence without a secure airway.

To the authors’ knowledge, there is no definitive evidence that deep extubation is superior to awake extubation, or vice versa. Each anesthesia practitioner should consider the individual patient and procedure, the provider’s experience and comfort level with deep-versus-awake extubation, and if there are adequate post-extubation resources available to monitor the patient.

Deep extubation is a useful technique and has its place in low-risk patients, particularly those undergoing certain procedures. However, anesthesia professionals should carefully weigh each scenario’s individual risks and the benefits of deep versus awake extubation.

Editor’s Note: The following article contains potentially sensitive content about suicide.

Death by suicide has been a widespread occurrence in antiquity across cultures. Physicians are not spared from this tragic end, with the first reported opinion in 1858 (A Manual of Psychological Medicine. 1858). This unfortunate problem has been studied for over 150 years, and these studies have at times revealed conflicting findings. While significant reductions in the incidence of death by suicide among physicians were seen in Europe through the early 21^st century, the United States unfortunately continued to see high rates of death due to suicide (PLoS One 2019;14:e0226361). Whether practicing physicians have a higher rate of death by suicide than the general population remains a subject of considerable debate. A 2004 meta-analysis by Shernhammer et al. of 25 studies determined that male physicians had a rate of death by suicide 1.47-times that of the general population, while female physicians were subject to more than double the risk (Am J Psychiatry 2004;161:2295-302). Dutheil performed a meta-analysis in 2019 and published similar findings, while also noting that 1% of physicians attempted death by suicide and 17% acknowledged suicidal ideation (PLoS One 2019;14:e0226361). Duarte et al. confirmed the higher incidence of death by suicide among female physicians but found that male physicians experienced a lower rate than the general population (JAMA Psychiatry 2020;77:587-97).

The incidence of death by suicide among anesthesiologists compared with the general population and other physicians is unclear, although it appears that we are at higher risk. A 1968 study of causes of death among anesthesiologists indicated that the risk of death by suicide for anesthesiologists was 1.5-times the general population (Anesthesiology 1968;29:565-9). A follow-up study completed in 1974 comparing anesthesiologists with male standard policy life insurance holders also revealed that death by suicide was the only area where this cause of death exceeded that of general policyholders (Anesthesiology 1974;41:71-4). Alexander’s often-quoted 2000 study of cause-specific mortality of anesthesiologists found that anesthesiologists have higher rates of early death due to suicide, substance use disorders, and other external causes when compared with internists (Anesthesiology 2000;93:922-30). Higher risks of death by suicide have been suggested among anesthesiologists and psychiatrists, but other studies have not confirmed this (JAMA Psychiatry 2020;77:587-97). Plunkett’s 2021 systematic review revealed that the proportion of anesthesiologists dying by suicide was increased in relation to comparator groups and that suicidal ideation was present in 3.2%-25% of individuals and attempts in 0.5%-2% of individuals (Anaesthesia 2021;76:1392-403).

Multiple factors contribute to the inconsistent findings in studies of death by suicide among anesthesiologists and other physicians. Anesthesiologists may have higher rates of death due to accidental overdose than other specialties, and it is often difficult to determine whether fatal overdose is accidental or intentional. Overdose has been referred to as a “silent contributor” to opioid deaths (N Eng J Med 2018;378:1567-9). When individuals die alone, the cause of death is inferred from findings at the scene and is subject to the bias of the investigator (N Engl J Med 2018;378:1567-9). Terminology, fears of litigation, and state-level factors may influence the ultimate finding of the cause of death (N Engl J Med 2018;378:1567-9). The stigma associated with death by suicide as well as attitudes toward psychiatric illness may result in nondisclosure of the nature of the event (Anaesth Intensive Care 2003;31:434-45). The other factor is that surveys of death by suicide are retrospective by nature and largely rely upon individual and institutional recall, an inaccurate method to collect critical data. Factors that may contribute to this tragic ending, such as social isolation, may further cloud memories of the individual. Perhaps the study of death by suicide requires a different approach.

No medical specialty has established a formal means to routinely track the incidence of death by suicide. Federal agencies such as the Centers for Disease Control and Prevention, Veterans Administration, and Federal Bureau of Investigation collect information for reporting purposes. Agency data are primarily objective and generally collected from sources such as the National Death Index. These databases serve a valuable purpose but are not specific for anesthesiology or other specialties and lack detail about factors that could potentially identify individuals who are at high risk beyond mere membership in a high-risk demographic group. The authors implemented a new method to track death by suicide among anesthesiologists – a confidential collection mechanism called the Anesthesiologist Database on Death by Suicide (ADDS). The project originated within the ASA Working Group on Mental Health and Suicide Prevention, which reports to the Committee on Physician Well-Being.

The purpose the ADDS is to formalize the reporting of routine as well as detailed demographic and situational data related to anesthesiologist deaths by suicide as early after the event as possible. This strategy is consistent with the recommendation of the Association of Anaesthetists that documentation of physician suicide by specialty be improved (Anaesthesia 2020;75:96-108). Early collection may minimize errors associated with periodic surveys, including errant recall. We expect the database will facilitate better insight into factors that can potentially lead to suicidal ideation and death as well as warning signs that are often ignored or minimized. These factors may be identified in the period after an event but are often lost to memory at the time a survey is performed. The database is designed so that any anesthesiologist may submit information. Duplicate submissions are reviewed to establish a more complete picture of any individual event. Collected data include primary objective demographic identifiers such as age, gender, ethnic group, status as a trainee or attending, and years in the position. Other factors commonly identified as risk factors for death by suicide are also included, such as work-related problems, litigation, prior substance use disorders, legal issues, negative childhood experiences, and physical and mental health problems. The Massachusetts General Hospital Institutional Review Board approved the database.

The database entry process was initially distributed to ASA leadership, society committees, and the House of Delegates. Data on 56 deaths (F=18, M=38) have been submitted to date. The data include 13 resident physicians. This limited sample size precludes definite conclusions or recommendations, but early findings indicate that women who die by suicide are far younger than their male colleagues (average 36 years versus 46 years, respectively).

The ADDS is a worthwhile, dynamic initiative that will further characterize factors that contribute to death by suicide for years to come. It is endorsed by ASA leaders. Much like the Closed Claims Database, data derived from the collection of additional information about anesthesiologist suicides in a confidential, secure manner can be used to educate the anesthesiology community about the risk factors and early warning signs of death by suicide. The survey is now being shared with the general ASA membership with the hope that additional submissions, now and going forward, will help anesthesiology practices and organizations to develop strategies for early intervention, appropriate treatment, and, ideally, return to successful careers. ASA members can enter information into the database through redcap.link/anes_suicide. Additional resources for suicide prevention strategies can be found at asahq.org/advocating-for-you/suicide-prevention, which is curated by the ASA Committee on Physician Well-Being. Readers will soon have the option to access the survey on the site.

• If you or a colleague are suicidal and need emergency help, contact:
  • 911 immediately or
  • The National Suicide Prevention Lifeline at 988 or
  • Crisis Text Line by texting HOME to 741741.
• The National Suicide Prevention Lifeline also published a resource, Suggestions to Help Someone Else: “Do They Need Your Help? How Can You Help Them?” (988lifeline.org/help-someone-else).