13 Sep 08
Edited by Emilio B. Lobato, Nikolaus Gravenstein, and Robert R. Kirby. 1008 pp., illustrated. Philadelphia, Lippincott Williams & Wilkins, 2008. ISBN 978-0-7817-8263-0.
Contemporary anesthesia is an important “safety paradox” of excellent outcome despite routine risk. Although it carries perhaps the greatest potential for hazard for millions of patients annually, anesthesia also has medicine’s best track record for the safety of patients. Gone are the days of patients’ “taking a bad anesthetic” and nothing more being said. Now the clinician rightly carries the burden of accountability, and nothing less than near-perfection is satisfactory. Even though some interventions in Western medicine are believed — perhaps naively — to have the potential to save thousands of lives if added to conventional practice (e.g., proprietary “care bundles” for patients suffering from sepsis), conventional anesthesiology performs very well indeed. We know this from epidemiologic data, and for those less easily persuaded, the reduction in anesthesiologists’ malpractice premiums over the past decade should convince.
This book is about complications, and it is the prevention of complications that makes a practice safe. The recent film Awake initially scared the profession and shocked the public about safety in anesthesia. But it did much more than scare — it focused attention on the potential for harm in an area that most see as harmless. This is crucial, because anesthesia has advanced to a stage where it appears simple and is practiced largely in the background. Indeed, many people do not know that anesthesiologists are physicians, do not know the difference between nurse anesthetists and anesthesiologists, and have little idea about what is done during the induced coma that constitutes their general anesthetic.
In this sense, anesthesia is a victim of its own success, building on decades of overwhelming accomplishment in the safety of patients, to the extent that studies of adverse events in anesthesia are difficult to perform — because serious adverse events, although dangerous, are rare. Beyond the public perception, the safety paradox has an unfortunate association with research and further improvement; anesthesia shares (with orthopedic surgery) the ignominy of being allotted the least funding through the National Institutes of Health research training grants. Thus, assumptions of safety — perhaps coupled with ignorance of risk — may have translated into thinking that ongoing research and development in anesthesiology do not matter.