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Who's Putting You Under?

When considering surgery, most people don't think about who's holding the lifeline in the operating room: the anesthesia provider. Though it's safer than ever, there are still risks involved.


Few patients preparing for surgery ever bother to ask who will be putting them under. They typically focus on finding a good surgeon--or the right hospital or clinic--giving little thought to the person who will be giving them anesthesia.

While it's important to pick the right doctor and setting for your surgery, it's your anesthesia provider who is entrusted with keeping you alive.

Sure, anesthesia today is safer than it was years ago. Mortality rates have dropped from about 1 in 10,000 in the early 1980s to an estimated 1 in 250,000, according to several studies.

Yet even with better monitors and medications, it's tricky work to alter consciousness and temporarily paralyze a patient.

A host of things can go wrong: sudden and potentially dangerous changes in blood pressure, severe drug reactions, excessive bleeding or a halt in breathing that requires resuscitation. And in rare instances, patients can die.

For the Record
Los Angeles Times Monday October 16, 2000 Home Edition Health Part S Page 3 View Desk 1 inches; 34 words Type of Material: Correction
Mistaken reference--An article about anesthesia providers in the Oct. 9 Health section gave the wrong gender for a Pasadena dentist who has been charged with 64 counts of child endangerment and unprofessional conduct. The dentist is a woman.

Dr. Ronald Katz, a USC anesthesiologist who has taught anesthesia for years, warns students there are unknowns each time a patient is put under: How will the drugs work together? How will the patient's body react to them? "All drugs are dangerous," he notes, "and anesthesia consists of multiple drugs."

While potential risks are known, there is a lack of good safety data to pinpoint the reasons why problems occur. "It's very hard to differentiate when somebody has a complication. Is it the anesthesia? Is it the surgery? Is it patient disease?" said Dr. Lee A. Fleisher, an anesthesiologist at Johns Hopkins Hospital in Baltimore.

Fleisher and researchers in Great Britain have estimated that anesthesia is directly responsible for 1 in 183,000 deaths during surgery. Though that indicates that anesthesia is relatively safe, Fleisher believes that where you have your surgery influences safety. He and colleagues reviewed 170,000 Medicare patients who underwent outpatient surgery. They found that the safest place was a free-standing surgery center, while the least safe was a doctor's office.

Advances in anesthesia have made it possible to move more surgeries--often cosmetic procedures--out of hospitals and into doctors' offices. At the same time, there is growing concern about the unregulated nature of surgery done in doctors' offices, where there is scant oversight by medical officials and few government reporting requirements.

Some highly publicized cases, including five deaths of patients undergoing elective surgeries in Florida, have heightened concern and prompted debate in medical circles. Some of the Florida deaths have been linked to anesthesia problems, prompting that state's medical board in August to impose a three-month moratorium on general anesthesia in outpatient offices.

The ban has prompted concern that some cosmetic surgeons are circumventing the restrictions by relying more heavily on deeper intravenous sedation, which may pose a greater risk of serious breathing complications.

"We're getting reports all over the state" of such incidents, said Dr. David Mackey, an anesthesiologist with the Mayo Clinic in Jacksonville, Fla.

Only a few other states, including California, Texas, New Jersey and Rhode Island, regulate office-based surgery. Ohio prohibits general anesthesia in offices.

Given the risks, it pays to be informed. Patients should ask about the credentials and experience of whoever will handle anesthesia and know how a facility is equipped for emergencies.

That knowledge is becoming increasingly important as insurers push for delivery of more medical care outside the hospital in less expensive outpatient clinics and doctors trying to protect their income operate in the more lucrative arenas of the ambulatory surgical center or private office--further from peer review.

Most consumers are unaware that medical doctors with special training in anesthesiology aren't the only health professionals allowed to put patients under.

Nurse-anesthetists have been around for more than a century. About 27,000 practice today. They are specially trained to deliver and monitor the medications that provide sedation and pain relief.

A certified registered nurse-anesthetist completes two to three years of graduate training following a bachelor's degree and at least one year of critical care nursing. Three of the nation's 90 accredited nurse-anesthesia programs are in California: at the Samuel Merritt College in Oakland, at Cal State Fullerton and at USC. The programs include advanced anatomy, physiology, pharmacology and anesthesia practice, and about 1,000 hours of hands-on experience.

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