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| LETTER TO THE EDITOR |
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| Year : 2022 | Volume
: 6
| Issue : 4 | Page : 254-255 |
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The “brick” anesthesiologist: Another stone on the wall
Bambang Tutuko1, Marilaeta Cindryani2
1 Department of Anesthesiology and Intensive Care, Premier Bintaro Hospital, Banten, Indonesia
2 Department of Anesthesiology and Intensive Care, Sanglah General Hospital, Denpasar, Indonesia
| Date of Submission | 14-Apr-2022 |
| Date of Decision | 26-Jul-2022 |
| Date of Acceptance | 26-Jul-2022 |
| Date of Web Publication | 31-Oct-2022 |
Correspondence Address:
Marilaeta Cindryani
Department of Anesthesiology and Intensive Care, Sanglah General Hospital, Jl. Kesehatan 1, Denpasar 80114
Indonesia
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/bjoa.bjoa_110_22
How to cite this article:
Tutuko B, Cindryani M. The “brick” anesthesiologist: Another stone on the wall. Bali J Anaesthesiol 2022;6:254-5 |
In the era of the 2000s, a new concept of intensive care unit (ICU) was promoted as ICU without a wall, a concept in which ICU was implemented beyond the walls of the unit. ICU was initially made to employ only critical care management for those who were prone to multiple organ dysfunction and death. Since its development, the mortality rate in the ICU is still quite high even though has been provided with comprehensive care. Therefore, the optimal care paradigm has shifted as early as possible and no longer focuses on optimization in the ICU, but has started from the emergency unit.
Anesthesiologist holds a vital role in three compatible yet challenging places, namely emergency unit, operating theater, and ICU. Lack of competence is not the only problem that has arisen but also lack of experience in crisis management and team communication have been one of the burdens in managing patients into a unified linear treatment since admitted to the emergency room (ER), treated in operating theater, and monitored in ICU.
According to the joint World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia in 2018, there are several safe practice standards that need to be employed in the scope of providers, techniques, facility levels, health-care facilities and equipment, medications and intravenous fluids, and monitoring.[1]
For instance, in standards for medications and intravenous fluids table of WHO-WFSA, it is written that several intraoperative and resuscitative medications should be available in the operating room (OR).[2] Half of the recommended drugs are familiar drugs in the ICU, but maybe not so in the OR. Some anesthesiologists definitely feel that there is no need to use these drugs in the OR, but the importance of “ICU without wall” concept is that the management of at-risk patients has been planned and started since the patient is still in the OR and is not rushed to be completed in the ICU. This concept also prevents the ICU from becoming a wastebasket, the final stage of patient death, and a place of blaming culture among doctors. Patient management is more conceptualized, earlier, and has clear goals.
Plenty of ICU management and strategies are already under research to be employed as early as in the OR. Protective lung ventilation that used to be acute respiratory distress syndrome modality now is highly credited to bring lower complications in patients who underwent surgeries.[2]
Boateng and Moitra[3] have predicted the future decade of critical care medicine in which some of the changes taking place include the transition to personalized medicine, advanced monitoring and organ support, sustainability in the ICU, and an increased emphasis on improving clinician wellness. To improve bedside practice and transition to more personalized ICU care, research that investigates diagnostic error, barriers to implementing best practices, and resource allocation relative to goals of care will be essential.
Stiegler et al.[4] actually have suggested cognitive errors in anesthesiology, which are still relevant in recent today issues. Some of our colleagues were caught lazy to use assistive devices such as ultrasound to install invasive devices namely central venous catheters, measuring volume adequacy, doing profound nerve blocks, placing difficult airway or intravenous access, in which by doing it repeatedly rush, risk of complications, and unpredicted error are increased. Feeling lazy and unaccustomed seem to hideously uncredited compared with those risks that tend to lead to malpractice.
Tran et al.[5] had proposed an idea that critical care physicians (CCPs) trained as anesthesiologist-extenders and acting under the supervision of an anesthesiologist to fill the void of scarce number of practicing anesthesiologist. Researchers concluded that CCPs could function at a level similar to that of a certified registered nurse anesthetist (CRNA) in a resource-limited setting, under a board-certified anesthesiologist’s direct supervision.
The concept of ICU without a wall was made to sharpen life-saving efforts from upstream in the ER to immediately eliminate the emergencies, solidify treatment and corroborative interdepartmental opinions, and finalize therapies while reducing patient interdependence with its surroundings. To reduce the height of the “wall,” an absolute willingness is needed not only based on the system but started from the health-care workers.
Anesthesiologists as the key pivotal worker in those three divisions should lower their egos, start taking on a more supportive role, be open to suggestions, and be ready to be asked for advice as early as possible. Must be willing to learn new tools, change perspective and diagnosis according to the latest evidence-based medicine, equip ourselves with statistical abilities, and train to get agility in operating recommended WHO-WFSA standard monitors. Anesthesiologists should stand with a fluid and graceful composure, not as a “brick” on the barrier wall that has been wanting to get rid of for a long time. By looking at the patient as a unified whole, we will also see ourselves as one of the constituents of the quality assurance system, not as an opposing party.
Financial support and sponsorship
Not applicable.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Gelb AW, Morriss WW, Johnson W, Merry AF, Abayadeera A, Belîi N, et al; International Standards for a Safe Practice of Anesthesia Workgroup. World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. Anesth Analg 2018;126:2047-55.  |
| 2. | Coppola S, Froio S, Chiumello D. Protective lung ventilation during general anesthesia: Is there any evidence? Crit Care 2014;18:210. |
| 3. | Boateng A, Moitra VK. Anesthesiology 2030: What does the future hold for critical care medicine? ASA Monitor 2021;85:38-40. |
| 4. | Stiegler MP, Neelankavil JP, Canales C, Dhillon A. Cognitive errors detected in anaesthesiology: A literature review and pilot study. Br J Anaesth 2012;108:229-35. |
| 5. | Tran QK, Mark NM, Losonczy LI, McCurdy MT, Lantry JH 3rd, Augustin ME, et al. Using critical care physicians to deliver anesthesia and boost surgical caseload in austere environments: The critical care general anesthesia syllabus (CC GAS). Heliyon 2020;6:e04142. |
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