Stress-Free Anesthesia? - Not for the Anesthesiologist!

"God will not look you over for medals, degrees, or diplomas, but for scars."

- Elbert Hubbard

"More volume!" "How high is the epi?" "Is the amiodarone load in yet?" "Here's the femoral line, flush when ready!!" "How much MR is there?" "Why is the balloon not working?"

For the cardiac anesthesiologist coming off bypass, this cacophony of demands and questions following one another in rapid succession is not unusual. Though our personal epinephrine levels may be skyrocketing, as we are trying to respond to the multitude of demands placed on us, we all feel the elation (and relief!) that comes when we finally bring our patient to a point of hemodynamic equilibrium. Yet, as we all know, the scenario is not always this rewarding. The national morbidity and mortality statistics indicate that at least 2% of our coronary artery bypass graft patients die and our valve patients may fair even worse. As a practicing cardiac anesthesiologist for over 20 years, and from the vantage point of over 6000 cases, I have personally experienced the frustration of having patients who have not reached that "hemodynamic equilibrium" even after extensive efforts by the entire team. Losing a patient, after prolonged heroic efforts, is traumatic to all involved, including the perfusionist, cardiac surgeon, nurses and technicians. Although we may know that we performed to the highest standards, this is often little consolation and does little to alleviate the stress we feel.

Certainly, the evolution of anesthesia over the past 20 years with major advances in equipment, pharmacology, and techniques has provided an increasingly stress-free perioperative experience for patients. This should translate to a "lightening of our load", yet for the cardiac anesthesiologist, this has not been the case. In fact, our success in providing ever-safer anesthetics has extended surgical care into populations previously avoided, resulting in increasingly aged and ill patients needing our perioperative expertise. With the advent of improved invasive cardiologic advances, a transition has occurred in the type of patients coming to the operating room over the last few years. Older, sicker, and unstable patients seem to be the rule. When was the last time you provided care for a "bread and butter", double jump, coronary artery bypass graft? How often is renal failure, diabetes, obesity, and hypertension a common theme on your patients' preoperative evaluation?

Thus, a paradox exists: as we find safer and more effective ways to care for our previously challenging patients, the scope of our practice is extended to even more difficult areas.

While the overall benefit to society may be creating a more "stress-free" anesthesia experience for a greater patient population, we as practitioners have only seen the challenges (and the associated stress) increase. We have all experienced the high intensity pressure of caring for the deteriorating patient that goes on hour after hour and perhaps throughout the night. After multiple hours of trying to stabilize a patient, whose tenuous hold on life is slowly slipping, each of us is left drained, both mentally and physically. The hours of clamped jaws, strained hamstrings, and a numb brain from the constant stress cannot be relieved until the patient's final outcome is determined. It doesn't really matter whether the case was a "success" or not, we often are left questioning whether we did all that we could do. Therefore, after hours of high intensity stress, we leave the operating room emotionally and physically exhausted. For most of us, life does not stop here. We are now expected to fulfill all our other roles as completely as we did in the OR, be that as educator, administrator, colleague, friend, spouse or parent (or even all of the above!). …. and the next day you are expected to jump back into the fray with full vigor and vigilance. How is this possible?! Michael Roizen, M.D., a past president of the Society of Cardiovascular Anesthesiologists, points out in his book Real Age, that length of life has been correlated with stress levels. Constant stress can affect us mentally, emotionally and physically. As physicians, and particularly as cardiac anesthesiologists, we have chosen to dedicate ourselves to the care of some of the very sickest patients. We bring extensive training and caring professionalism to the practice of cardiac anesthesia and manage to keep patient safety our foremost goal, even in the face of incredible stress on a routine basis. Yet, we are avoiding the age-old warning of "Physician, heal thyself", if we do not recognize the toll our profession can take on our physical and mental well-being. It is our responsibility to be ever cognizant of how we can support each other both in and out of the hospital. After all, who knows better the challenges we face daily then we ourselves?

March 30th has been designated Doctor's Day and I would like to take this President's Message to celebrate the dedication and professionalism you have shown by taking on the grave responsibilities of being a cardiac anesthesiologist. So the next time you hear, "Oh no, the aorta's dissecting", realize that you are not alone. We have all been there and will certainly be there again! When you are constantly dealing with human lives, stress is a job hazard that cannot be changed. However, we can recognize the challenges we all face and be there to support our colleagues…sometimes a few words of encouragement or a pat on the back may be all it takes!

Roger Moore, MD
President

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