Time Pressure and Regional Anesthesia

You learn very quickly in anesthesia residency that surgeons have little patience, especially for case delays. The key to keeping your surgeon happy is to keep the cases on schedule. We lament about this; no one complains if a surgeon takes longer than expected for a case, but if there's an anesthesia delay, we never hear the end of it. I actually think this is one of the biggest barriers to acceptance of regional anesthetic techniques. Surgeons are used to the speed of general anesthesia. A nerve block in the most skilled hands might take five extra minutes. A tougher block, more inexperienced practitioner, or a catheter technique can take ten or fifteen minutes.

We ought to do what is best for the patient, but sometimes surgeon preference trumps other priorities. I would hope that waiting five or ten minutes would not be a big deal, but somehow it is. And so if a surgeon is consistently delayed or if turnover time is longer than he expects, he may ask us to proceed with a general anesthetic rather than nerve block technique. I think we often acquiese though the best thing for the patient might be regional anesthesia.

Academic institutions try to address these issues with clever approaches. We have a nerve block service with a separate attending, fellow, and residents that perform all the nerve blocks needed. That way the regional team does the block rather than the anesthesiologist assigned to the case. Since we aren't providing anesthesia for ongoing surgeries, we can do the nerve block in advance, minimizing turnover delay. This also allows for a small cohort of regional attendings to ensure a high rate of success. However, the downside to this model is financial; the department loses money by paying for an attending to do nerve blocks rather than operating room anesthesia. This is why private practices rarely have a separate team, and instead rely on the assigned anesthesiologist to do an efficient, safe, and effective block.

But I don't think changing our delivery models is the only answer to this problem. We need to change the culture of the operating room so that it does not revolve around any of the providers, but instead focuses on the patient's needs. In pediatrics, for example, surgeons don't pressure us as much. They understand that separating a child from her parents, inducing anesthesia, placing an IV, and putting in a nerve block can take a variable amount of time. More importantly, they respect that what we do requires skill and isn't always straightforward. We don't feel as much time pressure to hand off the case. So in pediatric anesthesia, the assigned anesthesiologist performs the nerve block while everyone else waits. We do what we think is best for the patient.

This idea needs to trickle through the rest of the health care system. There may be other reasons to have a separate regional anesthesia team such as efficiency or cost. But an anesthesiologist should never choose an anesthetic technique simply because a surgeon won't wait for the block to set up.