Hello ladies and gentlemen.
Welcome back to our last lecture
in our series of lectures on Anesthesiology.
In this lecture I'm going to delve back
into my memory banks a little bit and tell you
something of the Evolution of Anesthesiology
during my nearly 40 years in this specialty.
Then we're going to discuss
what I see as being Future Areas of Development
in Anesthesiology. And my own personal
vision of Perioperative Medicine
and how it may evolve.
So, the last 40 years since I've been an anesthesiologist
there have been dramatic changes in our
specialty. One of the most important has been
a change in the behavior of the people working
in the operating room. When I started anesthesiology
as a resident, way back in the 1970s,
the surgeon was a god. Behavior by the surgeon
was often extraordinarily inappropriate,
throwing instruments, temper
tantrums, very bad jokes,
trying to get the nurses embarrassed
or laughing, or in some cases crying.
It was very manipulative and there was often
a war between the anesthesiologist and the surgeon.
This has changed dramatically. It's partly
because hospitals and hospital systems
will no longer allow this kind of behavior.
It's partly because nursing personnel
have become more assertive and more sure of their own
rights. And it's partly because the relationship between
surgeons and anesthesiologists has
improved dramatically in collegiality.
There's now a real appreciation
of the skills that we all bring to the team.
And the team is a very important part
of the system that acts to provide
surgery to patients. The surgeon,
of course, is still
a vital part of that team. And the system
is set up to support the surgeon.
And that is not going to change, nor should it change.
There needs to be assistance to the surgeon at all
points in the operation. However, the skills
that the nurses bring to the table
are really phenomenal. In an orthopedic
procedure such as a total hip replacement
or a total knee replacement, there are literally
hundreds of pieces of equipment that the scrub nurse
has to keep track of, and provide to the surgeon
at exactly the right moment. It's really
an amazing dance that occurs. And there's
great respect now between scrub nurses
and the surgeons they work with.
The circulating nurse operates,
basically runs the whole operating room.
It's the circulating nurse's duty to bring equipment in,
to take equipment out,
to provide information to
the waiting areas as to when surgery will be done,
to notify the recovery room when a patient
is ready to go there, to notify the holding area
when it's nearly time for a patient to come
from there for the start of surgery. They provide
a great deal of support to the anesthesiologist
in terms of providing us with the pieces
of equipment we need, particularly when things
are challenging, such as in a difficult airway
situation. The operating room is a great place
to work. It's clean, it's air
conditioned, the teamwork
involved is tremendous. And working with a bunch
of professionals, each of whom knows
his or her own job in real detail
is a real treat. The only negative
thing about it is, you have to wear a mask and they get
to be a bit smelly after a while, but that's a pretty minor
complaint in the bigger picture. Things that
have changed in other ways during that
period of time, have been our care of patients.
The biggest revolution that occurred during
the time I've been an anesthesiologist, is the introduction
of Pulse Oximetry in the early 90s.
It absolutely revolutionized our care
of patients. We went from a point where
the only way we knew things were going badly was if
the patient's color changed. In other words, they became
bluish, cyanotic. When that happened,
it usually meant we had less than
a minute to figure out what was going on
and correct it, before the patient arrested.
With pulse oximetry we know way in advance
if there's a problem and we can work on dealing
with it well in advance of any crisis.
The result of that has been
a marked decrease in the numbers
of operating room deaths. The second
big introduction was the introduction
of End-Tidal Carbon Dioxide. For the first
time we knew exactly how we were ventilating our patients.
We knew exactly whether we were ventilating
too much, too little, we knew what pressures we were
using, but most importantly, we knew what minute
ventilation was producing, the correct acid base
balance for our patient in terms of their end-tidal
CO2. This was a very important
change as well. Other changes
that have occurred, although not quite as dramatic,
have also been extremely important. The fiber optic
bronchoscope has been available for many
years, but it only became small enough
to put through endotracheal tubes
in the 1990s. And it wasn't until the 1990s
that awake intubation became something
that every anesthesiologist should be able
to do with skill and with
compassion. Other areas
have included the Development of Pain
Medicine, particularly Acute Pain Services.
Acute pain was an area, basically
a large black box in healthcare in
the 1980s. And it wasn't until the late 1980s
and 1990s that anesthesiologists
took over the treatment of patient's pain
from surgeons. Surgeons were basically
not terribly skilled at dealing with pain and unfortunately
not very interested. Anesthesiologists,
on the other hand, are skilled at dealing with pain and most
of us are very interested. We were able to change
the way patients were treated postoperatively very
dramatically, and that's been a very, very positive
move both for the patients and for the anesthesiologists,
because it got us back on the wards.
It got us back in the position of working with the staff
on the wards as real participants
in the larger healthcare team, that cares
for patients from admission to discharge.