Guess Who's Putting You Under

By MICHAEL D. LEMONICK

Last year Dr. Ron Miller was in a hospital pre-op unit doing what he has done every week for more than three decades: administering an anesthetic to a patient headed for surgery. Miller served as an anesthesiologist in the Vietnam War and now chairs the department of anesthesia at the University of California, San Francisco, School of Medicine; it's hard to imagine someone with more experience or better credentials. Even so, he was taken by surprise when he gave a low dose of a moderate sedative called midazolam, designed to put the patient into a semiconscious state, somewhere between sleep and wakefulness--and the man stopped breathing. "There is no way of predicting that a patient would have responded that way," he says. "I've been doing this for years, so I was prepared." He managed to revive the man.

But just imagine, says Miller, what might have happened if that had taken place outside a hospital, without a trained anesthesiologist present. A decade or two ago, such a scenario would have been farfetched because most surgery was done in hospital O.R.s.

Not anymore. "What we call outside-the-operating-room anesthesia is exploding," says Dr. Orin Guidry, president of the American Society of Anesthesiologists. It's not that doctors are doing heart bypasses or hip replacements or radical mastectomies on an outpatient basis. "If you're going to take a person apart," says Dr. Warren Zapol, anesthetist in chief at Boston's Massachusetts General Hospital, "you need to control the airways, paralyze the muscles and do things that amateurs don't want to do."

But there has been an enormous increase in less drastic procedures. Cardiologists are performing many more angiograms and other invasive tests than they did a couple of decades ago. Plastic surgeons are doing more liposuction procedures and partial face-lifts. Gastroenterologists are doing more colonoscopies and endoscopies--snaking a tube in from one end or the other of the digestive tract to take pictures. "Where 15 years ago endoscopy was a rare procedure," says Guidry, "now everybody's expected to have one periodically. There's tons of stuff that just wasn't done before."

There is simply no way trained anesthesiologists can meet the demand--especially since the increase in surgeries has been accompanied by a simultaneous increase in what anesthesiologists are asked to do. "At UCSF," says Miller, "we manage all of the post-op pain, we run all of the recovery rooms, and we man all of the preoperative evaluative clinics."

That helps explain why, at a rough guess, some doctors estimate that 45% of all sedation today is handled by people other than anesthesiologists. "There are tens of thousands, maybe millions, of sedation procedures done satisfactorily by other physicians," Guidry says. Still, a 2003 study published by Dr. Hector Vila, chief of anesthesiology at the University of South Florida's College of Medicine, showed 10 times the risk of death or permanent injury for surgery performed in doctors' offices rather than in ambulatory surgery centers. The difference, Vila concluded, was largely due to lax anesthesia procedures. In an extreme example, he says, "one plastic surgeon had his girlfriend giving the anesthesia. It didn't take long for something to go bad."

In the wake of that study, Florida has stricter training and certification rules for people administering office-based anesthesia; 21 other states have some sort of guidelines. Some individual health-care systems have created their own tighter rules. And the anesthesiologists' society released new guidelines last fall to help hospitals and clinics establish credentialing processes for nonanesthesiologists who provide sedation.

Since each patient's response to anesthesia can be different, as San Francisco's Miller was reminded last summer, the guidelines are intended to ensure that whoever administers the drugs should be able to rescue a patient from one level of sedation deeper than the level intended (see chart). "Our job is flying in bad weather," says Zapol. "A fair number of hearts stop in operating rooms, or people stop breathing. The key thing in training is to make people confident at resuscitation."

As for the type of sedation a doctor will aim for in a given operation, there are no hard-and-fast rules. In general, operating on the extremities offers more options than operating on the body's core, but the dividing lines between levels of anesthesia can be blurry. Once you get away from major surgery, pain control and sedation are often mixed and matched according to patient preference. Says Dr. Ronald Pearl, chairman of the department of anesthesia at Stanford: "It's not uncommon when we do a spinal anesthetic, say for knee surgery, to ask the patients whether they want to be awake or asleep for it." Those who choose sleep do so not because they want to avoid the pain--they won't be feeling it in either case--but because they just don't want to know they're under the knife.

But choosing to stay awake doesn't mean a patient is free of the risks of anesthesia. "We can get in trouble with a local anesthetic," says Zapol. "We can get in trouble with a spinal anesthetic," which keeps pain signals from getting to the brain but doesn't make the patient sleepy. "We can overdose you in all of those places." Someone, whether it's an anesthesiologist, another physician or a fully trained nurse, has to be ready to deal with that possibility. "Surgeons are experts at kidneys and ureters and coronary arteries and lungs. They're skillful people," Zapol says. But someone has to keep the rest of the body going while they operate.

With reporting by Reported by Dan Cray/ Los Angeles