Changes in Anesthesiology – The Future of Anesthesia

00:06 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.

00:42 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.

01:18 It was very manipulative and there was often a war between the anesthesiologist and the surgeon.

01:24 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.

01:48 There's now a real appreciation of the skills that we all bring to the team.

01:54 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.

02:12 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.

04:18 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.

04:42 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.

06:06 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.

06:48 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.