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Back to the Future: Anesthesiology Style with Courage!

Schwartz, Alan Jay MD, MSEd

doi: 10.1213/ANE.0b013e318252eb95
Editorials: Editorials

From the Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania.

Supported by the Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia.

The author declares no conflicts of interest.

Reprints will not be available from the author.

Address correspondence to Alan Jay Schwartz, MD, MSEd, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, 34th St. & Civic Center Blvd., Room 9327, Philadelphia, PA 19104-4399. Address e-mail to

Accepted February 7, 2012

Remember the hit movie “Back to the Future”?1 It offers anesthesiologists, like us, a wonderful opportunity to ponder what patient care might have looked like in a time different from today. Imagine what you would think if you were the anesthesiologist described below:

A clinical anesthesiologist, who finished his core anesthesiology residency in 2008 and provides anesthesia patient care in a modern-day, state-of-the-art, well-equipped hospital, finds himself unexpectedly transported back in time 30 years into the earlier version of the same operating room (OR) suite in which he currently works; the OR lacks modern-day medical technological resources.

Being assigned to care for the next patient, he proceeds with the induction of general anesthesia and is immediately distracted by the need to fiddle with the hard-to-hear and difficult-to-properly-position stethoscope wedged under the blood pressure cuff wrapped around the patient's arm and attached to a finicky aneroid, only intermittently providing manual (nonautomated) blood pressures; he hopes these measurements accurately reflect the patient's physiology and that he will remember to inflate the cuff and assess the data consistently.

Somewhat rattled and knowing better from his modern education, the clinician stumbles upon the next disconcerting event; when the incision is made and the surgeon comments with worry in his voice, “The blood looks dark!” the anesthesiologist realizes that there is no pulse oximeter to rely upon! How deafening is the absence of the pulse oximeter beep!

The anesthesiologist's upset intensifies as events get even worse when at the end of the case the patient resumes spontaneous respiration after having received muscle relaxant and neuromuscular reversal agent and there is no reliable way for the displaced modern-day clinician to evaluate adequacy of ventilation, because he can't measure end-tidal carbon dioxide. When the patient's wakeup seems to be taking a longer time than expected and residual anesthetic is a consideration in the differential diagnosis of the delayed emergence, the clinician has to smell the contents of the anesthesia bag to estimate the quantity of exhaled inhalation anesthetic that is present, because end-tidal agent analysis is not available.

The next patient to anesthetize is scheduled to undergo a craniotomy; our anesthesiologist knows invasive hemodynamic monitoring is indicated. His intent to use a pressure transducer and oscilloscope is thwarted when he discovers that these monitors are scarce; other practitioners have grabbed the available devices for the care of their own at-risk patients and the supply is exhausted. Having come from the future, our hero knows what he needs to do for patient safety and realizes that he will be unable to comply, because there is no reliable way to continuously monitor intraarterial blood pressure.

The modern-day educated anesthesiologist cares for a variety of additional patients in his setting of 30 years ago. All of his cases proceed in similar unsettling fashion yet, thankfully, and he thinks amazingly, the patients fare well; he definitely, however, wants to be back to the future that he has learned to depend upon!

Do you recognize this scene? I remember this vividly; I lived it as recounted. It is really not that long ago (1973) that I started my anesthesiology residency under circumstances exactly as described for our displaced clinician. Most of our patients fared well; not all, however!

When our anesthesiologist finally found his way back to the future he appreciated the amazing opportunity to have had a glimpse of what anesthesia patient care was before modern-day patient safety monitoring was available. He thought for a minute and wondered if all anesthesia patient care proceeds as he learned it in the 21st century. He asked several pointed questions: “Is the present, back to the future, or is it, the past?” and “What is the current state of affairs of anesthesia patient safety monitoring around the world?”

In this month's Anesthesia & Analgesia, Juan and colleagues,2 as if answering our fictitious practitioner, provide some insight to the questions, “Is the present, back to the future, or is it, the past”? and “What is the current state of affairs of anesthesia patient safety monitoring around the world?” These clinical anesthesiologists evaluated the current state of affairs of anesthesia patient safety monitoring in their home country, China. Their investigation keyed in on whether availability of anesthesia patient safety monitoring equipment in China was similar to other locations in the world in 2012 or more representative of care in 1982. They surveyed example hospitals of all sizes in all geographic and economic regions of China, collecting data about currently available anesthesia patient safety monitoring.

Displaying courage to ask this question, Juan and colleagues provide answers through a description of a case series that documents that patients in China, especially when cared for in economically underdeveloped regions and in smaller hospitals, may undergo anesthesia care in ORs where pulse oximetry, capnography, invasive hemodynamic monitoring, and end-tidal anesthetic gas monitoring may not always be available. Why is it so? The authors explain that anesthesiology has only recently gained professional status among all physician groups in China. Lack of status has accounted for the lack of support by hospital administrators who, until recently, did not allocate resources to supply patient safety monitors in sufficient quantities.

It is 2012 and there is now more than a quarter of a century of clinical science that supports the need for and benefit to patients from implementation of standardized patient safety monitoring. The landmark publication by Eichhorn et al.3 formalized a scheme for standardization of patient safety monitoring during anesthesia patient care. This set the stage for the American Society of Anesthesiologists (ASA) to promulgate the first iteration of its patient monitoring standards (in 1986) that have been refined and updated on a regular basis (“… last amended on October 20, 2010 …”).4 Implementation of the ASA standards has become a worldwide activity.5 Juan and colleagues cite some of the many countries around the globe that have adopted the ASA standards; when one views the web site of the Chinese Society of Anesthesiology, it is not obvious that the ASA standards (or an equivalent document) have been adopted.

Juan and colleagues guide us to the World Federation of Societies of Anaesthesiologists' (WFSA) initiatives and World Health Organization's (WHO) Guidelines for Safe Surgery that, (a) provide evidence of better patient outcome when patient safety monitoring is an essential part of anesthesia patient care; and (b) guide implementation of such standards.6 No Chinese anesthesiologists are acknowledged as authors or contributors to the 2009 WHO Guidelines for Safe Surgery.6 The WFSA (of which the Chinese Society of Anesthesiology is a member) is a primary supporter of the WHO Guidelines.7

The WFSA mandate is explicitly articulated, stating that when,

“… not even those standards regarded as mandatory are met … the provision of anesthesia under such circumstances should be restricted to procedures, which are absolutely essential for the urgent or emergency saving of life or limb, and every effort should be made by those responsible for the provision of healthcare in these areas and settings to ensure that the standards are met. Provision of anesthesia care at standards lower than those outlined as mandatory for anesthesia for elective surgical procedures simply cannot be construed as safe acceptable practice [emphasis added by the author]. The most important standards relate to individual anesthesia professionals. Monitoring devices play an important part in safe anesthesia as extensions of human senses and clinical skills rather than their replacement.”8

What is the WFSA mandate? Anesthesia professionals must provide patient care and this care must include patient safety monitors that exponentially “extend” the expertise of the anesthesia professional.

A current public health initiative championed by the WFSA's and WHO's ideal for safe surgery including safe anesthesia patient care is epitomized in the Lifebox project whose vision statement implores:

“Our vision isn't just about distributing hardware and it doesn't stop with pulse oximetry. The provision of equipment is a nod, not a solution, to the dangerous shortfalls in global health provision. Education, training, and peer support are key.”9

Lifebox is a public health initiative geared to enhance the level of anesthesia patient care in developing countries around the world. One would assume that China's economic status would not be a stumbling block to the use of modern patient safety monitoring during anesthesia care and implementation of the same standards and principles as the Lifebox initiative.

Reading “Availability of Anesthesia Equipment in Chinese Hospitals: Is the Safety of Anesthesia Patient Care Assured?” in Anesthesia & Analgesia may raise questions about the scientific rigor of this investigation, or concern for potential conflict of interest because manufacturers of monitoring equipment supported this study about inadequate supply of monitoring equipment. Focusing on these types of concerns is necessary and appropriate to guarantee the integrity of the science. At the same time, these concerns must not divert our attention or cloud the more important message and inferred clinical mandate from Juan and colleagues; if even one patient is denied implementation of anesthesia patient safety protocols for which there is positive worldwide consensus, this must be identified and corrected. How fortunate it is that Chinese anesthesiologists have partners like Juan and colleagues, who are willing to raise tough questions about anesthesia patient care standards, collect answers, and identify areas for enhanced clinical care and then share this information with their countrymen and all of us.

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Name: Alan Jay Schwartz, MD, MSEd.

Contribution: This author wrote the manuscript.

Attestation: Alan Jay Schwartz approved the final manuscript.

This manuscript was handled by: Sorin J. Brull, MD, FCARCSI (Hon).

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1. Back to the Future. Universal Studios, 1985
2. Juan X, Xinqiao F, Shanglong Y, Yuguang H, Buwei T, Shiying Y, Pengqian F, Hanqing Z. Availability of anesthesia equipment in Chinese hospitals: is the safety of anesthesia patient care assured? Anesth Analg 2012;114:1149–53
3. Eichhorn JH, Cooper JB, Cullen DJ, Maier WR, Philip JH, Seeman RG. Standards for patient monitoring during anesthesia at Harvard Medical School. JAMA 1986;256:1017–20
4. American Society of Anesthesiologists. Standards, Guidelines, Statements and Other Documents. Available at: Accessed January 17, 2012
5. Cooper JB. Towards patient safety in anaesthesia. Ann Acad Med Singapore 1994;23:552–7
6. World Health Organization. WHO Guidelines for Safe Surgery 2009. Available at: Accessed January 17, 2012
7. World Federation of Societies of Anaesthesiologists. Safety and Quality of Practice Guideline. Available at: Accessed January 17, 2012
8. World Federation of Societies of Anaesthesiologists. 2008 International Standards for a Safe Practice of Anaesthesia. Available at: Accessed January 17, 2011
9. Lifebox. Available at: Accessed January 17, 2012
© 2012 International Anesthesia Research Society