The Crowd That Isn’t There

When I walk into an empty operating room, I can hardly force my way through the crowd that isn’t there.

Anesthesia is remarkably safe, with preventable intraoperative mortality now being so low that it is hard to quantify. But it was not always so. Consider how different practice was during my anesthesia residency 4 decades ago.

Equipment included reusable red-rubber endotracheal tubes and copper kettle vaporizers. Blood pressures were obtained by manually inflating cuffs and listening for Korotkoff sounds. Anesthesia machines were poorly designed, which encouraged errors, and then failed in dangerous ways. With a copper kettle, for example, reducing fresh gas flows nonintuitively increased inspired volatile anesthetic concentration. Some machines lacked interlock systems to prevent administration of hypoxic gas mixtures (eg, 100% nitrous oxide), and many did not even include an oxygen analyzer. Consequently, patients died because anesthesiologists who reached to turn off nitrous oxide accidentally discontinued oxygen administration.

Consider also the monitors that we now take for granted, such as pulse oximeters, expired CO₂ and anesthetic monitoring, ultrasound, esophageal Doppler, processed EEG, and noninvasive advanced hemodynamic estimates. Many were not yet invented, and none were generally available. Thiopental was the short-acting induction agent, isoflurane was the short-acting volatile anesthetic, and curare was the short-acting muscle relaxant.

Tens of thousands of person-years were required to develop our current panoply of anesthetic monitors, and modern integrated systems contain dozens of them. Developing new drugs requires an even larger effort. And then, there are all the patients we learned from—including the ones we hurt. Nor can we forget hundreds-of-thousands of patients who volunteered for various anesthesia studies that now guide our practice.

Anesthesia did not become safe by magic. Safety resulted from the efforts of thousands of skilled clinicians, educators, and dedicated investigators, and of course patients, all of whom contributed to enhancing anesthesia safety. I’ll never forget how much we owe to the people who aren’t in the room.