Three apparently unrelated occurrences during the past few months illustrate some challenges being faced by obstetric anesthesiologists. They may also provide opportunities for SOAP members to influence the future of obstetric anesthesia practice.
First was an informational communication to the SOAP Board of Directors from Joy L. Hawkins, MD, Chairperson of ASA's Committee on Obstetrical Anesthesia. Dr. Hawkins acquainted the Board with an ongoing correspondence between herself and representatives of the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONNpronounced A-one) concerning AWHONN's position statement on the "Role of the Registered Nurse in the Management of Analgesia by Catheter Techniques." Within that statement, under the heading "For the Pregnant Woman," was included "The insertion, initial injection, or initiation of a continuous infusion of epidural catheters for analgesia should be performed only by a qualified and credentialed, licensed anesthesia care provider as described by the American Society of Anesthesiology, [sic] Guidelines...and the American Association of Nurse Anesthetists...[r]ebolus of an epidural catheter includes injection of the catheter by syringe or increasing the rate of a continuous infusion." AWHONN had used the ASA Guidelines to preclude its members from injecting or even adjusting flow through epidural catheters when the block was inadequate or required modification.
In a well-reasoned response Dr. Hawkins addressed the lack of morbidity and mortality data supporting the introduction of a national policy on the role of the obstetric nurse in this regard. She pointed out that local policies had apparently worked satisfactorily. In addition, she made the very cogent point that nurses frequently administer potent medications by other routes so why should the care of an epidural catheter be any different?
In a follow-up letter from AWHONN, Judith H. Poole, RNC, MN, Chair, Committee on Practice, reported some results from a member survey on this topic. One thousand members responded, of whom 765 did not "intervene independently and manage the patient should there be a negative response to the analgesia." Of the 235 who do intervene, they do so because "anesthesia is unavailable." [Italics mine]
Second was the request I received from ASA for SOAP's opinion of the questions developed by the Ad Hoc Committee on Performance Based Credentialing (PBCC). ASA did not seek answers to the questions, rather SOAP's input was sought relative to the design and appropriateness of the questions themselves. I sought input from the other members of the Board of Directors, then forwarded a response to the ASA committee. The next step in this process will be to circulate the finalized questions to the specialty societies and others and use the resultant answers to develop practice parameters.
Third was the event that generated a volume of e-, voice-, and snail mail that overwhelmed me for more than a weekthe August issue of Good Housekeeping. In an article entitled "The Best Doctors for Women" the magazine engaged in an increasingly popular publishing endeavor in which it listed the 401 "best" gynecologists of all subspecialities in the U.S.A. Of course, my correspondents were not commenting on the choicesalmost all recognized people on the list possessing dubious diagnostic skill and technical abilityno, almost to a person the complaint was the non-inclusion of anesthesiologists on the list. "Don't they realize that the advances made in the care of women would have been impossible without the contributions of anesthesiologists?" was the oft-repeated theme.
Why do I believe these seemingly disparate events are similar? In short, because they speak to our failure as anesthesiologists to educate those around us including patients, nurses, other physicians, health care administrators, and the general public.
The AWHONN chronicle, now more than five years in duration, results from a lack of information and presence of misinformation that should have been preventable had we acquitted our educational responsibilities at the individual hospital level. Simply put, we should ensure that labor nurses understand what it is that we do and assure their level of comfort with what we ask of them. The question of what anesthesiologists should reasonably expect an obstetric nurse to know and do with regard to a woman receiving epidural analgesia during labor obviously has many answers depending on the local practice situation and the personnel involved. In many countries, nurses routinely re-inject epidural catheters and otherwise manage labor blocks. These nurses are apparently educated to recognize and initiate treatment of related problems. In the U.S.A., nurses initiate cardiac arrhythmia treatment, routinely administer potent respiratory depressant drugs, monitor fetal well being and institute appropriate treatment, function as physician extenders in a variety of roles, and have been extremely vocal in requesting recognition as "professionals." Thus, there is no question that properly trained nurses have the ability to undertake the additional monitoring requirements attendant upon epidural labor block, and may have the capacity to play an even greater role depending on their desire to be educated to that extent.
The concept of practice parameters is anathema to some, suggesting as it does that the art of medicine can somehow be evaluated on the basis of a list of attributes, and that, further, decisions on physician qualifications, privileges, et cetera, should be based on those measures. The push to develop practice parameters demonstrates, in part, recognition that the current methods by which society (e.g., hospitals) evaluates physicians and their practices have shortcomings. The ASA President has charged the relevant committee with developing those parameters within a relatively brief time. SOAP will play as large a role as it can in this endeavor.
The popularity of physician lists in the lay press is a response to the perceived inability of organized medicine to rank and rate physicians. Consumers are somehow reassured when they see that the car they drive has been rated highly by Consumer Reports and their nephrologist by Rolling Stone. The fact that there has not been a list of the country's (world's, universe's) best obstetric anesthesiologists simply reflects the fact that nobody has thought that there would be value in producing one. We have not yet educated our colleagues or magazine editors. Or perhaps we are only legends in our own minds!
Gerard M. Bassell, M.D.
President, SOAP