Proposed time limits for anesthesia may have compromised patient safety

After a public outcry, Anthem Blue Cross Blue Shield announced Dec. 5 that it had dropped plans that would have placed time limits on health insurance payments for anesthesia care in certain states. But the brief brouhaha shed light on an often overlooked but central component of surgical care.

Anesthesiologists don’t just put people down, says Amy Vinson, a pediatric anesthesiologist and wellness expert at Boston Children’s Hospital. They also monitor a person’s vital signs and pain levels before, during and after surgery. If a crisis occurs, such as a sudden drop in blood pressure or severe bleeding, the anesthesiologist administers vital fluids and medication.

“There may be [nurses and surgeons] who come out of the operating room,” says Vinson. “But the one real constant is a member of the anesthesia team who is right there with the patient … from the moment anesthesia care begins pre-operatively until it stops in the recovery room.” Their presence during a procedure means anesthesiologists often become the patient’s de facto support person, adds Vinson.

Placing time constraints on anesthesiologists, and by extension, surgeons, can make those in the operating room feel rushed, says anesthesiologist and pain physician Alopi Patel of RWJ Barnabas Health in New Brunswick, NJ, and that, she says, can endanger patient safety.

Everything from individual patient physiology to unexpected incidents in the operating room can affect the length of an operation (SN: 28.7.15). “You can average the operation times. But you can’t say that only if the standard [procedure] takes two hours, now we will allow only two hours. Every patient is different,” says Patel, who spoke to him Scientific news in her capacity as a member of the communications committee for the New York State Society of Anesthesiologists, in New York City.

Scientific news spoke with Vinson and Patel to better understand the role of anesthesiologists — an area that even many doctors don’t fully understand, says Vinson, whose comments reflect her personal views. Vinson and Patel’s comments have been edited for length and clarity.

SN: Many people do not fully know what anesthesiologists do. Can you explain your job?

Vinson: We care for patients before, during and after surgery for anything that requires pain management or sedation for surgery. We are the ones who give the patient medications, fluids and blood.

It is a big responsibility. We are taking over one’s entire physiology. We are managing their blood pressure, their breathing. If their heart rate goes up, we can lower it. If it comes down, we can bring it. Same with blood pressure. We are checking their ventilation and what medications they need. We paralyze their muscles temporarily so that their operation can continue.

We have a persona of being loving and joking around. A lot of that is intentional, because when you’re in a room, you have to have real control over that room. If there is a crisis, you must have all the attention at once. I am a really friendly person in the operating room. I joke a lot. I talk a lot. The moment I get my serious voice, everyone will pay attention.

SN: Why do you think putting time limits on anesthesia is a bad idea?

Vinson: Anesthesiologists are paid in a unique way in medicine. We are paid with time. And that’s because we have no control over how long the surgeon will take, and we’ll be with the patients until the surgery is done, no matter what.

[Automated systems] will create an estimate of a surgeon’s time for a given procedure based on their previous cases. If it’s a straightforward procedure, it would probably work in most cases. But it is an average. Some procedures will be faster and some will be slower. Time limits penalize the sickest patients. It penalizes surgeons who care for the sickest and most complex patients. And it penalizes the care teams and anesthesia teams that care for these complex patients.

SN: What factors can extend the expected duration of an operation?

Vinson: Every person’s body is slightly different. Let’s say a surgeon is performing heart surgery on someone who has had heart surgery before. They can’t open the chest again because of the scar tissue. You don’t want the surgeon to just go in, go through all this, causing a lot of bleeding and injury to the patient to meet a predetermined time that this operation has to take.

Or say the surgeon is operating on someone who is morbidly obese. This will be a very different approach to surgery [than the average patient]not only for actual surgical time but also for patient positioning.

Or when they go in to remove a tumor, they may find more than expected. The image does not see everything. And sometimes bad things happen. Sometimes an allergic reaction occurs.

SN: Can you tell me more about the interpersonal aspects of your work?

Vinson: We are meeting people at some of the most profoundly frightening times in their lives. These are operations that they have been waiting for or are coming as an emergency. They are often quite scared in the area before surgery. They have a lot of questions and we’ve never met them before. We have five or 10 minutes to have a focused conversation with the patient. During that time, we have to explain to them what we are going to do to keep them safe and we have to gain their trust to take over how their body works while they are sleeping. So it’s a tremendous amount of trust that they put in us at that point.

SN: Can you give an example of a specific patient interaction that exemplifies the work of an anesthesiologist?

Patel: I had a patient who needed emergency surgery. At the hospital, she discovered she had a blood clot in her lung. So, as with any type of anesthesia, we had to be very careful because the blood clot could move forward and basically cut off the blood flow to the rest of her heart. Everyone was working quickly to perform the operation because they knew it was urgent.

I could tell she was very nervous. I put on the monitors and explained the situation, saying: “We have to move urgently, but we have to be very gentle with the anesthesia.” I asked him what music he liked. She asked Yanni, a keyboard. She was basically able to submit to meditative music while I held her hand. Afterwards, she thanked me for being there for her and for being a human by her side and not just a doctor looking down in a mask and scrubs.