Proposed time limits on anesthesia may have jeopardized patient safety

Following a public outcry, Anthem Blue Cross Blue Shield announced December 5 it had walked back plans that would have put time limits on health insurance payments for anesthesia care in certain states. But the brief brouhaha shined a light on an often neglected, yet central, component of surgical care.

Anesthesiologists don’t just put people under, says Amy Vinson, a pediatric anesthesiologist and expert in well-being at Boston Children’s Hospital. They also monitor a person’s vital signs and pain levels before, during and after surgery. Should a crisis arise, such as a sudden drop in blood pressure or heavy bleeding, the anesthesiologist delivers vital fluids and medication.

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

Putting time limits on anesthesiologists and, by extension, surgeons could cause those in the operating room to feel rushed, says anesthesiologist and pain physician Alopi Patel of RWJ Barnabas Health in New Brunswick, N.J. And that, she says, could jeopardize patient safety.

Everything from a patient’s individual physiology to unexpected incidents in the operating room can affect how long a surgery takes (SN: 7/28/15). “You can average out surgical times. But you can’t just say that if the standard [procedure] takes two hours, we’re now going to only allow two hours. Every patient is different,” says Patel, who spoke to Science News in her capacity as a member of the communications committee for the New York State Society of Anesthesiologists Inc., in New York City.

Science News spoke to Vinson and Patel to better understand the role of anesthesiologists — a field that even many doctors don’t fully grasp, says Vinson, whose comments reflect her own personal views. Vinson and Patel’s comments have been edited for length and clarity.

SN: Many people don’t quite 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 a surgery. We are the ones giving medications, fluid and blood to the patient.

It’s a tremendous responsibility. We are taking over someone’s entire physiology. We are managing their blood pressure, their breathing. If their heart rate goes up, we can bring it down. If it goes down, we can bring it up. Same with their blood pressure. We are controlling their ventilation and what medications they need. We paralyze their muscles temporarily so that their operation can proceed.

We have a persona of being affable and kind of joking around. A lot of that is intentional, because when you are in the room, you need to have real control over that room. If there is a crisis, you need to have all the attention immediately. I’m a really friendly person in the operating room. I joke around a lot. I chat a lot. The minute I get my serious voice, everyone is going to 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’re paid by time. And that’s because we don’t have any control over how long the surgeon is going to take, and we’re going to 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 prior cases. If it is a straightforward procedure, maybe that would work in most cases. But it’s an average. Some procedures are going to be faster and some are going to be slower. Time limits penalize sicker patients. It penalizes the surgeons who care for the sicker, more complex patients. And it penalizes the care teams and the anesthesia teams who care for these complex patients.

SN: What factors can extend the expected length of a surgery?

Vinson: Every person’s body is a little bit different. Let’s say a surgeon is doing a heart surgery on someone who’s had heart surgery before. They can’t just open the chest again because of scar tissue. You don’t want the surgeon just going in, barreling through all of that, causing a lot of bleeding and harm to the patient to fulfill some predetermined amount of time that this surgery should take.

Or say the surgeon is operating on someone who has morbid obesity. That’s going to be a very different approach to the operation [than the average patient], not just for the actual surgical time, but also for the positioning of the patient.

Or when they go in to take a tumor out, they may find more than expected. Imaging doesn’t see everything. And sometimes bad things happen. Sometimes an allergic reaction happens.

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

Vinson: We are meeting people at some of the most profoundly frightening moments of their lives. These are operations that they’ve been waiting for or they’re coming up as an emergency. They’re often quite frightened in the pre-op area. They have a lot of questions, and we’ve never met them before. We’ve got five or 10 minutes to really have a focused conversation with the patient. During that time, we’ve got to explain to them all of what we’re going to do to keep them safe, and we’ve got to earn their trust to take over how their body functions while they’re sleeping. So it’s a tremendous trust that they place in us in that moment.

SN: Can you give an example of a specific patient interaction that illustrates an anesthesiologist’s job?

Patel: I had a patient who needed emergency surgery. In the hospital, she found out that she had a blood clot in her lungs. So, as with any sort of anesthetic, we had to be very careful because the blood clot could move forward and basically decrease blood flow to the rest of her heart. Everyone was working fast to get the surgery done because they knew it was urgent.

I could tell that she was very nervous. I put on the monitors and I explained the situation, telling her, “We have to move urgently, but we also have to be very gentle with our anesthesia.” I asked her what music she wanted. She asked for Yanni, a keyboardist. She essentially was able to zone out to the meditative music as I held her hand. Afterward she thanked me for being there for her and being a human next to her rather than just a doctor looking down with a mask and scrubs.